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BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT SERVING <br /> AI Crow.Pres. Sen Joaquin County <br /> Earl Pimemel.Vice Pres, 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton,California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mask M.D. JOGI KHANNA. M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews Cly of Ripon <br /> Thomas Schuberk D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (203) 468-3420 City of Stockton <br /> Harvey Williams,PhD. Sen Joaquin County <br /> AU-r C3FZ I ZAT I C3 P4 TO FiNEE L_EASE <br /> is ANALYTICAL RESULTS <br /> +F GEOTECHNICAL DATA <br /> 4+- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 4-) 3-.) VJk-g�T In/o,( ST�zl�ioy <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE F6 L <br /> (LABORATORY or CORSDLTARU <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND%OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRE•SrENTATIVE. <br /> BUSINESS NAME: lV 0MELt-I ry I (p�nJ T�[[cT/OnJ CCS <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: cSoNnl\/ S/I/pnlAS) { F/-QLJQ�7r "A,-J4GE�12 <br /> (PLEI PRINT) <br /> ($1610I01E) <br /> ADDRESS: __ /eqPDC /S2� <br /> (11!1!16 ADDRESS) <br /> (CITY) (STATE) (IIP) <br /> PHONE: 620') ) <br /> DATE: 4 LD•8� <br /> EH 23 041 Revised 1/83 <br /> Administration Clinical Services EnNronmental Health Public Health Nursing <br /> 468.3400 468-3890 468-9420 468-3860 <br /> Air Pollution Community Services Laboratory yylC <br /> 480-3470 468.3820 468-9460 468-3260 <br /> AIDS Information 488-3820 <br />