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BOARD OF TRUSTEES SAIjOAQUIN LOCAL HEALTH DISACT <br /> At Crow„Pres. SERVING <br /> Earl Pimentel,vice Pres. 1601 East HazeltOn Avenue San Joaquin County <br /> Tommy Joyce,Secy. StocktonCalifornia 95205 City of Manteca <br /> , <br /> James F.Culbertson City of Escalon <br /> John D.Mast,M.D. JOGI 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 City of Ripon <br /> Daphne Shaw (.11.191 468-34;:0 San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> AUTHOR I ZAT I ON TO FZ EL EASE San Joaquin County <br /> 'M- ANALYTICAL RESULTS <br /> 4EOTECHNICAL DATA <br /> W- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> HE (STREET ADDRESS) <br /> HEREBY AUTHORIZE ZE <br /> all t F-� Ci, 1 �- [ 7 ; <br /> (LABORAIORY 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: <br /> I , <br /> (1F APPLICABLE) <br /> OWNER/OPERATOR: <br /> (PLEASE P (TITLE) <br /> ($[$NATURE) <br /> ADDRESS: <br /> (NAILINS ADDRESS) <br /> (CITY) (STATE) (ZIP) <br /> PHONE: C cct) Cj`4(i-��f <br /> i <br /> DATE: i” <br /> EH 23 041 Revised 1/619 <br /> Admin466/3400 stration Clinical Services Environmental Health Publlc Health Nursing <br /> 468-3830 468-3420 468.3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 466-3280 <br /> AIDS Information 468-3820 <br />