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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. 1.04 San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> ' Tommy Joyce,Sec'y. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Meso M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (,2C)'j) 4G8-3421 i City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County - <br /> ALJTHOF2I ZAT I ON TO F<EILEASE <br /> ANALYTICAL RESULTS <br /> E: GEOTECHNICAL DATA <br /> x- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OF,' OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 3/y O �Sa. T J'Z %AAGv G',!27 J-tr 37,4 <br /> (STREET ADDRESS) , T!IY) <br /> HEREBY AUTHORIZE raj.- I EenN �} 1✓gr�a �R�� <br /> (L480PATORY or COHSOLTANU <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OP. <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: ELJ JEFRIZZIIAZL44 ASO k4-O OL <br /> (IE APPLICABLE) <br /> OWNER/OPERATOR x / 710M FSS -_ c/� fQ-/t <br /> (P EASE PRI T) (IIT LE) <br /> Y <br /> 6 U E) <br /> ADDRESS: <br /> Y NEW JERUSALEM SCHOOL l <br /> 3J4-- "- -- <br /> (NARLY6 ,4DDRESS) TRACY,CA- 95376 <br /> y (209)835-2597 <br /> (CITY) (SIVE) (ZIP) <br /> PHONEX (Zpq 7 <br /> x / <br /> DATE: &/0 <br /> EH 23 041 Revised I/89 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Service; Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3620 <br />