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fiOARD OF TRUSTEES 5+ 4 JOAQUIN LOCAL HEALTH D13TRICT SERVING <br /> AI Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue Cory u Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISIONCity of Ripon <br /> Daphne Shaw - San Joaquin County <br /> Harvey Williams,Ph.D. <br /> 0209? 468-3420 City of Stockton <br /> San Joaquin County <br /> AU-r C3 FR I ZAT I ON TO RELEASE <br /> 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 /y3 r :549cPall/V Sr. 's-rar I <br /> (SIREEI ADDRESS) I (CITY) ' <br /> HEREBY AUTHORIZE Cg,LlFag yja ! /��¢ <br /> (LADORAIORY or CONSULTAND <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 /> J(1E APPLICABLE) <br /> OWNER/OPERATOR: ,/ L� 119 A/ kaeg, <br /> (PLEASE PRINI) (VILE) <br /> ,/ ('I " - � i� <br /> (SIGNATURE) <br /> ADDRESS: e �j annN �T <br /> (NAILING ADDRESS) <br /> �(Z77J/�r Pir g ''„fie 5� <br /> (CITY) (STATE) (ZIP) <br /> PHONE: <br /> DATE: ' — C> <br /> .2 <br /> EH 23 041 Revised 1/85 <br /> Administration Clinical Services Environmental Health Public Health Nursin <br /> 468-3400 468-3830 468-3420 468-3860 g <br /> Air Pollution community Services laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Informelion 468.3820 <br />