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0 ! <br /> 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 Escaion <br /> James F.Culbertson City of Lodi <br /> John D.Meat,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 (209) 468-3421) City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTH[DR I Z A•T- I MN TO RaL-a E3E <br /> �+- ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> �+- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OP. OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT i S G 1 S SE.VF-1~1TH STP-e-zF-`T' <br /> (SIREEI ADDRESS) Utly) <br /> HEREBY AUTHORIZE GF-0 jk"NL:L�.-n('-f:ht L LA C j MODEz'TO CA . <br /> (LABORATORY or CORSULTAAT) <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 A5 SOON AS IT IS AVAILABLE AND AT THE SAME~ TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: LNNQ7ar©N M ARZ EST' <br /> 11F APPLlCA9LE17Wt�€ S w �>aJ�-t-T+ C� <br /> OWNER/OPERATOR:_ .SAMca Lit f2iUEL+L_ J'kr.# LV_ R tC KSf <br /> � ASF PRlIlf) - (TYLE) <br /> (S1GRAruRE) <br /> ADDRESS: ___--- -O_.__f3 c�i� '117 LATE-12Q`P -4CJ P-, 2�iM S2 <br /> (MA1LUG ADDRESS) <br /> L-k-T-KRIO I✓ Gk 95330 <br /> (City) (Stiff) (IIP) <br /> PHONE$ ( :P-09) <br /> EH 23 041 Revised 1/09 <br /> Administration Clinical Servicos Envlronmenol lieatth Public Heatth Nursing <br /> 468-3400 468-3830 460-3420 460.3860 <br /> Air Pollution Community Services Laboratory Wi W <br /> 4610-3470 468-3920 468-3460 468-3200 , <br />