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BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. Sen Joaquin County <br /> Earl Pimemel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,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 (2o'31) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTHOR I ZAT I ON TO REL.EAS1= <br /> ANALYTICAL RESULTS <br /> �•E GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR. OPERATOR, OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 20851 S Sutliff Road Escalon - <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE California water lab, carpenter rd. , Modesto, Calif. <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 NAME: 't—jzA <br /> (IF PPL(CABLE) <br /> :EP)OPERATOR: "�&' e PYf30W <br /> (PLEASE PRINT) (TITLE) <br /> —z (SIWIATURE) V <br /> p <br /> ADDRESS: F) / - t Y✓1-.4���� �/1 <br /> (NAlI(N6 A DRESS) <br /> (CITY) (STATE) (lip) <br /> PHONE: (;t D k) �� — �/ <br /> DATE: <br /> EH 23 0141 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 460-3400 460-3830 468-3420 468-3060 <br /> Air Pollution Community Services Laboratory WIC <br /> t 468-3470 468.3820 468-3460 460-3200 <br /> AIDS Information 468-3820 <br />