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BOARD OF TRUSTEES SAN OAQUIN LOCAL HEALTH DISTRI16 SERVING <br /> At Crow,Pres. <br /> Earl Pimentel,vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,SecCity of Mantecay. Stockton, Calilornla J5205 City of Escaion <br /> James F.Culbertson City of Lodi <br /> John D.Mask M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews <br /> Thomas Schubert,D.V.M, ENVIRONMENTAL, HEALTH DIVISIONCity of Ripon <br /> San Joaquin County <br /> Harvey Williams,Ph.D.Daphne Shaw (209) 468-3420 City of Stockton <br /> San Joaquin County <br /> �4U-r 0F;Z I Z^T I C3 h# -r C3 MEL-EASE <br /> - ANALYTICAL RESULTS '' <br /> - - GEOTECHNICAL DATA <br /> - ENVIRONMENTAL/SITE ASSESSMENT INFORMATION [AN' R0NfVENTAL;AEA <br /> I , THE UNDERSIGNED OWNER, AND/OR OPERATOR OF THE PROPERTY AND/OP, FACILITY <br /> LOCATED AT 99 WEST 6TH STREET TRACY, CA <br /> HEREBY AUTHORIZE (STREET ADDRESS) (City) <br /> (L410P410Ry 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 /> °t <br /> BUSINESS . NAME: <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: CITY OF TRACY <br /> (PLEASE PRINT) (111LE) <br /> t L <br /> (SIPAIURE) <br /> ADDRESS: 560 S. TRACY BLVD. <br /> (NAILING ADDRESS) <br /> TRACY CA, 95376 <br /> (City) (STATE) (lip) <br /> PHONE: ( 20 ) 836-4420 <br /> DATE: <br /> EH 23 041 Revised 1/09 <br /> Administration Clinical Services Environmental Health Public Hoalih Nursing <br /> 468-3400 468-3830 469-3420 468-3860 <br /> Air Pollution Community Servlcas Laboratory WIC <br /> 468-3470 468-3820 468-3400 468-320D <br /> A Ir11�tninIrn ACIt 9q^n <br />