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BOAR6 OF TRUSTEES SANIOAQUIN LOCALHEALTH DISTRICT <br /> AI Crow,Pres. sEnVING <br /> Earl Plmental,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton, California95205 <br /> James F.Culbertson Stockton, City of Manteca <br /> John D.Mast,M.D. city of Escelon <br /> Virginia Mathews JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Thomas Schubert,D.V.M. City of Tracy <br /> Daphne Shaw ENVIRONMENTAL HEALTH DIVISION City Of Ripon <br /> Hervey Williams,Ph.D. (2v'3) 468-3420 San Joaquin County <br /> City of Stockton <br /> AU-r c:)FR 3: ZAT = op4San Joaquin County <br /> TO F2EL_EASE <br /> +t 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 1.7 ` At . (^(^r A./ At Lt e k) P-, . .1.. <br /> (SIREEI AUURESS) f s1 C R CT 7 W <br /> HEREBY AUTHORIZEnr r (CIfYI <br /> A l I'? w 1 ( <br /> TO RELEASE ANY AND ALL <br /> 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 /> FBIUSINESS : IIII APPLICABLE)R: Q �LC(PLEASE P IXi) lllEl <br /> (S-141' <br /> A111 / <br /> ADDRESS: <br /> �rA'Aj(IX6 AUURESSI <br /> (City) <br /> CC'' <br /> (Sr E) (IIP) <br /> PHONE: <br /> DATE: r� J sj 9 <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services <br /> 468-3400 - Environmental Health Public Health Nursing <br /> 468-3830 468-3420 <br /> Alr Pollution 468-3860 <br /> 468-3470 Community Services Laboratory _ <br /> 468-3820 488-3460 WIC <br /> 468-3280 <br /> AIDS Information 488-3820 <br />