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-w ANALYTICAL RESULTS <br />4c- GEOTECHNICAL DATA <br />-w ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED pOWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT 1755 /V , WcAv"V 51n-erk7?- t1 <br />(STREET ADDRESS) <br />1P1 <br />HEREBY AUTHORIZE_, ICLEINFELDEJ', rNC <br />A Y or DNSDLIANT) <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:___-BaA7 AwlCLx4yiy1L wt.)o—c <br />(IFgALI�CABLE) <br />OWNER/OPERATOR: WU� li6N-A)z-rV GJELY 6re- <br />(PLEASE PRINT) (TITLE) <br />(516NATURE) Q <br />ADDRESS: 2nl� I <br />(NAILING ADDRESS) <br />OA �6znl <br />(CITY) (STATE) (!IP) <br />PHONE: (?C-17) 46k -15q11 <br />DATE: Z --116 — 90 <br />EH 23 041 Revised 1/89 <br />Administration <br />Clinical Services <br />Environmental Health <br />BOARD OF TRUSTEES <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />SERVING <br />At Crow, Pres. <br />Community Services <br />San Joaquin County <br />Earl Pimentei, Vice Pres, <br />1601 East Hazelton Avenue <br />City of Manteca <br />Tommy Joyce, Secy. <br />Stockton, California 95205 <br />City of Escalon <br />James F. Culbertson <br />City of Lodi <br />John D. Mast, M.D. <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />City of Tracy <br />Virginia Mathews <br />City of Ripon <br />Thomas Schubert D.V.M. <br />ENVIRONMENTAL HEALTH DIVISION <br />San Joaquin County <br />Daphne Shaw <br />( 209) 468-3420 <br />City of Stockton <br />Harvey Williams, Ph.D. <br />San Joaquin County <br />AIJTHOFZ I ZAT I ON TO FRELEA$E <br />-w ANALYTICAL RESULTS <br />4c- GEOTECHNICAL DATA <br />-w ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED pOWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT 1755 /V , WcAv"V 51n-erk7?- t1 <br />(STREET ADDRESS) <br />1P1 <br />HEREBY AUTHORIZE_, ICLEINFELDEJ', rNC <br />A Y or DNSDLIANT) <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:___-BaA7 AwlCLx4yiy1L wt.)o—c <br />(IFgALI�CABLE) <br />OWNER/OPERATOR: WU� li6N-A)z-rV GJELY 6re- <br />(PLEASE PRINT) (TITLE) <br />(516NATURE) Q <br />ADDRESS: 2nl� I <br />(NAILING ADDRESS) <br />OA �6znl <br />(CITY) (STATE) (!IP) <br />PHONE: (?C-17) 46k -15q11 <br />DATE: Z --116 — 90 <br />EH 23 041 Revised 1/89 <br />Administration <br />Clinical Services <br />Environmental Health <br />468-3400 <br />468-3830 <br />468-3420 <br />Air Pollution <br />Community Services <br />Laboratory <br />468-3470 <br />468-3820 <br />468-3460 <br />AIDS Information 468-3820 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />