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DARD OF TRUSTEES S JOAQUIN LOCAL HEALTH DIF 11CT <br /> At Crow,Pres. ... ar/ SERVING <br /> Earl Pimentel,Vice Pres. 1601 East Hazellon Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginta Mathews • City of Tracy <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION � City of Ripon <br /> Daphne Shaw r , San Joaquin County <br /> (�,�1,_ 1 <br /> Harvey Williams,Ph.D. U 468-3420 City of Stockton <br /> AUTHOR I ZAT I ON TO RELEASE San Joaquin County <br /> 'X- ANALYTICAL RESULTS <br /> 1 <br /> "X- GEOTECHNICAL DATA <br /> i <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OP. OPERATOR OF THE PROPERTY AND/OP. FACILITY <br /> LOCATED AT �Ln�7 jY<'K MC(� /0 <br /> (SIRES! ADDRESS) <br /> HEREBY (CIfY) <br /> AUTHORIZE � ^ , <br /> TO RELEASE ANY AND ALL ANALYTICAL-REb LTS, GEOTECHNICAL DATA AND/OR <br /> t <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: —C <br /> TOP: Sa)h(Idf ArP�•`PoLLI..C—A,,KBLIlE,t) <br /> d <br /> L%i C <br /> (PLEASE PRINIJ (HILL9 <br /> (S1GNAfUREJ <br /> fi <br /> ADDRESS:_ � 14 o <br /> (/NAILING 4 <br /> 00RE5S) <br /> (CCHY) (ZIP) i{ <br /> PHONE: <br /> a <br /> } <br /> DATE:. Z3 q,1 A <br /> i <br /> EH 23-041 Revised 1/8.3 i <br /> R <br /> Administration Clinical Services Environmental Health <br /> i <br /> 468-3400 468.3830 Public Health Nursing <br /> 466-3420 468-3860 <br /> Air Pollution Community Services Laboratoryr <br /> 468-9470 468.3820 WIC r <br /> 468-3460 468-3280 <br /> y _ AIDS Information 413,8.3R" <br />