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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Grow,Pros. San Joaquin County <br /> AI C <br /> Earl ow,PimPre(vlcs Prea. 1601 East Hazelton Avenue City of Manteca <br /> . Stockton, California 95205 City of Escalon <br /> Tommy Joyce.Secy <br /> City of Lodi <br /> James F.Culbertson . <br /> John D.Mass,M.D. JOGI KHANNA. M.D., M.P.N., DISTRICT HEALTH OFFICER Cly of Tracy <br /> Virginia MathewsCity of Ripon <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (209) 46B-3420 City of Stockton <br /> Harvey Willlama.Ph.D. San Joaquin County <br /> ALJTHOF2I ZAT I ON TO RELEASE <br /> -�4- ANALYTICAL RESULTS <br /> ►t <br /> GEOTECHNICAL DATA <br /> -04- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT—7- �E�� y �E't tt c IJ�{P�T CKu�ISY�l1AL4 <br /> (SI EI ADDRESS) —� (CITY) <br /> HEREBY AUTHORIZE C P�Lt I– L--Ay`-�-; C+�vZtlf�Tor2 m06e.SU21 ' <br /> (LABORATORY or CONSDLIANT) <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 REPRESENTATIVE. <br /> ?6Fc.V56 y� .S7FrGS �C�LN�J <br /> BUSINESS NAME: FE.(/SE <br /> (IE APPLICABLE) 'I <br /> OWNER/OPERATOR: ,c%`> /"'4 �{AQ VIS F A1vtK0 ' �I�<>TEcTI^nl S.rl. <br /> (PLEASE PRINT) (TITLE) <br /> (S/ONAfURE) l/// <br /> ADDRESSL <br /> (NAILING ADDRESS) <br /> �t <br /> (CITY) (STATE) (LIN <br /> PHONES ( 2-'�"l ) x > 2 3�> <br /> DATE: <br /> EH 23 041 Revised 1/8'3 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services laboratory WIC <br /> 468-3470 486-3820 468-3480 468-3280 <br /> AIDS Information 486-3820 <br />