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µ, I <br /> BOARD OF TRUSTEES SAPJOAQUIN LOCAL HEALTH DISOCT SERVING <br /> Sen Joaquin Count' <br /> At Crow,Pres. <br /> Earl Pimento],Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escafon <br /> James F.CulbertsonCity of Lodi <br /> John 0.Mast,M.D. Jodi KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER' City of Tracy. <br /> Vlrginis Mathews Cly of Ripon <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Show (209) 468-3420 City of Stockton <br /> Harvey VAIliems,Ph.D. San Joaquin County <br /> AUT"C)R I Z AT I ON TO RELLEASE <br /> ae ANALYTICAL RESULTS <br /> x GEOTECHNICAL DATA <br /> -w ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> Ir THE UNDERSIGNED OWNER AND/OR. OPERATOR. OF THE PRO EP.TY AND/OR. FACILITY <br /> LOCATED AT <br /> (STREET ADDRE ) (ply,�� <br /> HEREBY AUTHORIZE <br /> AZ/G, /.l ) �4 <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 NAMES 5, 1" 5t�2d/c�S <br /> (!f APPLICABLE) / <br /> OWNER/OPERATORI _SGr__C / <br /> (PTA S f PR __�li1TLE) <br /> (SIGNATURE) <br /> ADDRESS: age A�•4dd /,i 1' <br /> (RAILING ADDRESS) <br /> (CITY) (STATE) (ur) <br /> PHONE s <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Servicoa Environmental Health Pubfic Health Nursing <br /> 468-3400 468-3830 460-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468.3400 468.3200 <br /> AICS hforr,'wn 463-3820 <br />