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L:OARD OF TRUSTEES <br />S1 JOAOUIN LOCAL HEALTH DIS;,�,4CT <br />SERVING <br />At Crow, Pres. <br />Earl Pimentel, Vice Pres. <br />1601 East HateltOn Avenue <br />San Joaquin County <br />Tommy Joyce, Secy. <br />Stockton, California 95205 <br />City of Manteca <br />James F. Culbertson <br />City of Escalon <br />John Most, M.D. <br />JOG] KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />City of Lodi <br />City of Tracy <br />Virginiais Mathews <br />Thomas Schubert D.V.M. <br />ENVIRONMENTAL HEALTH DIVISION <br />City of Ripon <br />Daphne Shaw <br />(2o9) 468-3420 <br />San Joaquin County <br />City of Stockton <br />Harvey Williams, Ph.D. <br />San Joaquin County <br />AUTHOR I Z AT I ON TO F+ELEASE <br />'W ANALYTICAL RESULTS <br />-� GEOTECHNICAL DATA <br />-34- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT /777 f, ,je/L(rc %F o% 1f7c`r7 <br />(STREET ADDRESS) (CITY) <br />HERESY AUTHOR I-ZE Cis-/iF lw�rJ'Co'L <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: ff-ftpTA *cT't- <br />(IF APPLICABLE) <br />OWNER,/OPERATOR: _AL(— E V ` /s <br />. ff—etff/V <br /><P ASE PRINT) (TITLE) <br />(S16NAfURE) �� <br />ADDRESS: 1771 <br />(NAILING ADDRESS) <br />(CITY) �1 (STATE) (ZIP) <br />PHONE: (L�-'X <br />DATE: <br />EH 23 041 Revised 1/89 <br />Administration Clinical Services Environmental Health <br />468-3400 468-3830 468-3420 <br />Air Pollution Community Services Laboratory <br />468-3470 468-3820 468-3460 <br />AIDS Information 468-3820 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />