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BOARD OF TRUSTEES SAArJOAQUIN LOCAL HEALTH DISI-QCT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sec'y. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw ( 0.3) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTHOR I Z^-r I C3" T O R E L E A S E <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OP, FACILITY <br /> LOCATED AT 257 GU, FleGE�,-) <br /> (SERIF! DDRESS) (CITY) <br /> HEREBY AUTHORIZE p-lIQM lF Lyle <br /> (LABORATORY or CONSULTANT) <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 /> BUSINESS NAME: <br /> /(IF APPLICABLE) <br /> OWNER/OPERATOR: _ 91hE,2AA. R16&4s N�ISo I) f(�£AJT�99/ill f i��✓7�oN <br /> �(PLEASE P�RIIKr) (TITLE) <br /> (SIGNATURE) <br /> ADDRESS: 1y0 sz-4elG,e d- <br /> (NAILING ADDRESS) <br /> S'�c Etyy e AL,Z 2U/9 952DS <br /> (CITY) (STATE) (ZIP) <br /> PHONE: ("-b 9 <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Envlronmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468.3280 <br /> AIDS Information 468-3820 <br />