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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRIq <br /> At Crow,Prea SERVING <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue l ._� San Joaquin County <br /> Tommy Joyce,sexy. Stockton, California 95205 city of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mask M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City o1 Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert.D.V.M. ENVIRONMENTAL HEALTH DIVISION City of Ripon <br /> Daphne Shaw (2t)9) 468-34.ryt) San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> AU-rHOR I ZAT I [7N TO RELEASE San Joaquin County <br /> x ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> Ir THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT IOC4Z E , �T C AME ��� T /1i,1 <br /> (STREET ADDRESS) (CITY) <br /> ! f <br /> HEREBY AUTHORIZE Roy. F, tnl Ink) OA- <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: _ ��CICI�rnyLT[jR�}L �/ �1�1 <br /> �/ (If APPLICABLE) <br /> OWNER/OPERATOR: _ ICUe"r NEv14"-17 - <br /> (PLEASE PRINT) <br /> (TITLE) <br /> ��7' ��sf76L <br /> (SIGNATURE) <br /> ADDRESS: _ P, D t (&)X 201 PS9 <br /> (NAILING ADDRESS) <br /> STOCKKTC-�j OA <br /> (CITY) (STATE) (ZIP) <br /> PHONE: ( 20 <br /> LDATE- <br /> EH <br /> 23 041 Revised 1/89 <br /> Adm6iiniss'rr�n Clinical Services Environmental Heafth Public Health Nursing <br /> 468-3830 468-3420 468.3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 460-3470 468.3820 468-3400 468-3200 <br /> AIDS Information 468-3820 <br />