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BOARD OF TRUSTEES SAP'JOAQUIN LOCAL HEALTH DISTRICT <br /> Al Crow,Pres. SERVING <br /> Earl Pimenlel,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 Escalon <br /> John D.Mast,M.D. JOG[ 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 Ciuinof Co my <br /> Daphne Shaw San Joaquin County <br /> (209) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. <br /> Sen Joaquin County <br /> AUTHOR I ZAT I C31-4 TO F�EFLEASE <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER, AND/OR OPERAT p, OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE -SF/7Jr <br /> (LABORAiDRY 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. j <br /> BUS I NESS NAME: �y d <br /> (IF APPLICA LE) <br /> OWNER/OPERATOR: <br /> ( LEA PRINT) Q ( LE) <br /> ,Q(SISNAIURE) <br /> ADDRESS: /.�. �jo- L <br /> (NAI IN6 ADDRESS) <br /> (CIITY))q // 7��17/ (STATE) (IIP) <br /> PHONE: (Aoo/ 9��-7 <br /> DATE: /y �90 <br /> EH 23 041 Revised 1/8.3 / <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468.3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />