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BOARD OF TRUSTEES SAI 10AQUIN LOCAL HEALTH DIST :T SERVING <br /> AI Crow,Free. "� <br /> Earl PimenteL Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton,California 95205 City of Manteca <br /> James F.Culbertson City of Escaton <br /> John 0.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION City of Ripon <br /> Daphne Shaw San Joaquin County <br /> .'Harvey Williams,Ph.D. (209) 4EG-34LU City of Stockton <br /> San Joaquin County <br /> AUTHORIZATION TO t-iELEASE <br /> x ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> -f►F ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OP. OPERATOR, OF THE PROPERTY AND/OP, FACILITY <br /> LOCATED AT_Z�iC G�yyJZT Z IvWr <br /> (SIREEI ADDRESS) (City) <br /> HEREBY AUTHORIZEM�— <br /> (LABORAI(IRy OP CONSULIANI) <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: Cyf/�L/?oiL%-�/S'f rDcn- Gnt2Ae,To/ <br /> (PLEASE fit iLN�I) (11^IILLE) <br /> I�r 2- �5 SK1�vL �I A e <br /> (SICNALURE) <br /> ADDRESS: <br /> (NAILIN6 ADDRESS) <br /> (City) <br /> (STATE) (ZIP) <br /> PHONE: <br /> DATE: <br /> I <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services ental EnvironmHealth <br /> 468-3400 468.3830 4 Environmental <br /> Public Health Nursing <br /> 468.3860 <br /> Air 468-3470 468-3820 <br /> Community Services Laboratory WIC <br /> 468-3820 468.3460 <br /> 468.3280 <br /> AIDS Information 46A•3820 <br />