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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of 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 City of Ripon <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (2o9i) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTHOR I ZAT I ODV TO RELEAS3D= <br /> �e ANALYTICAL RESULTS <br /> -FL- GEOTECHNICAL DATA <br /> M ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AToZ1I 4�,E'T/1 /f�e//i/� <br /> (SYREff ADDRESS) /� � (CIfY) <br /> HEREBY AUTHORIZE_ CA-n(O/�fl� <br /> (LABORATORY or CONSUL100 <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: e/2L/LC't`/!///� <br /> / (IF APPLICABLE) <br /> OWNER/OPERATOR: <br /> LEASE PR ) //� (i1TLE) <br /> (SI6141URE) <br /> ADDRESS: <br /> (1AILIN6 ADDRESS) �y <br /> (CITY) (SLATE) (IIP) <br /> PHONE: <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468.3830 468.3420 468-38W <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />