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004110 OF TRUSTEES • <br />Al crow, Pres, SAN JOAOUIN LOCAL HEALTH DISTRI <br />End Plmenlol, Vice Pres, !^'�' <br />TommyJoyce,,y. 1601 East Hazelton Avenue ``11 <br />Jame. F. Culberbon �,�% SERVING <br />John 0. Mas Stockton, California 95205 San Joaquin ce°nry <br />Virginia Mal ow �' A JOGI KHANNA,M <br />CIN of MantecaThomas CIN of Ese°lonDnphno chubert D•vM. ., .p,ll„ DISTRICT HEALTH CIN of .otl <br />l <br />CIN Tracy <br />Shew ENVIRONMENTAL HEALTH DIVISION CIN of RiponHony Willlema Ph.D, LI),J4GO-3420 San Joaquin CountyU <br />TI—IQFS I Zoc,, I QNCity Of Stockton <br />T Q San Joaquin County <br />�:cLE.a>�E <br />* ANALYTICAL RESULTS <br />-c- GEOTECHNICAL DATA <br />M ENVIRONMCNTAL/SITE ASSESSMENT INFORMATION <br />Ir THE UNDERSIGNED OWNER AND/Op, <br />OPEl: R <br />LOCATED ATOF THE PROPERTY AND/OR FACILITY <br />�j �'" � , <br />HEREBY AUTHORIZE ,I <br />a <br />TO RELEASE ANY AND _ �� <br />o� <br />RON <br />ADOAAroxr caxsuuexrl <br />ENVILE ALL ANALYTICAL RESULTS <br />ENTAL/SITE � r GEOTECHNICAL DATA AND/OR <br />ASSESSMENT INFORMATION TO <br />THE SAN .10AOUIN <br />AVAILABLE AND LOCAL HEALTH <br />DISTRICT AS SOON AS IT IS P, AT THE SAME TIME <br />TO ME OIT <br />MY REPRESENTATIVE, IS PROVIDED <br />BUSINESS NAME: <br />OWNER/OPERATOR; <br />(Ir Arr( <br />1 <br />($1GNA1UAC1 <br />ADDRESS:G1� <br />fNA!(1NG ADDRCSSI <br />(arr) — <br />PHONE: (,�ml qw- <br />DATE: — (o <br />EH 20 041 <br />Pevi,sed <br />f <br />rsrArr! rzrn <br />7�a � <br />Adminlstrollon <br />460.3400 <br />Clinical Sorvicos <br />--� <br />460-3030 <br />Environmental health <br />Air Pollution <br />463.3470 <br />Community SOrvICOs <br />460-3420 <br />'- <br />460.3020 <br />Laboratory <br />400-3460 <br />Public Health Nursing <br />460.3060 <br />WIC <br />460.3200 <br />