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BOARD OF TRUSTEES SPtWJOAQUIN LOCAL HEALTH DISMCT SERVING <br /> Al Crow,Pros. 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. JOG) 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 (2119) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> ALJTHOF;Z I ZAT I ON TO FZZELEASE <br /> x ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR, OF THE PROPERTY AND/OR, FACILITY <br /> LOCATED AT Q �3Lo a I r- mr" 2 k I f*c V C A cj 7l, <br /> (STREET ADDRESS) (CITY <br /> HEREBY AUTHORIZE h', G - L , I /9 V 1100 Vle/JT.fL <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: —54,J J04yi/!.) <br /> (IF APPLICABLE) <br /> OWNER./OPERATOR: V )� LL )n,ym �J , I S c9 Lt&j-e (-- <br /> (EASE PRINT) (TITLE) <br /> (S16NRiURE) p �y <br /> ADDRESS: T� CJr O / <br /> (NAILIN6 ADDRESS) <br /> � <_ <br /> (CITY) C� (SIArf) (ZIP) <br /> PHONE: (� C / S 75 <br /> DATE: <br /> EH 23 041 Revised 1/89 <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 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />