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a tIEERIfIG ACT/27 '69 15' 16 WALT01J . P.3/3 <br /> / 84ARD OF TRUSTEES SAN JOAOUIN LOCAL WEALTH DISTRICT SERVING <br /> Al Crow,Pros. San Joaquin County <br /> Fad Plmental,Vice Pray. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Seo'y. Stockton,California 95205 City of Escalan <br /> James F.Culbertson City of Lodi <br /> John 0.Mast,M.D. Jost KHANNA, M.D., M.P.N., DISTRICT HEA4TH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert0M.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 /> AUThiQFi I ZAT 10M 'rO FcEL_EASE <br /> -s:- ANALYTICAL RESULTS <br /> -rc- GEOTECHNICAL DATA <br /> >» ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER ANA/OR OPERATOR Of THE PROPERTY AND/OR FACILITY <br /> LOCATED AT C4QQ VJ. ✓ALpI (.,4 D j T+ C—)�f <br /> (SIREEf ADDRESS) (City) <br /> HEREBY AUTHORIZE rPA-h'•'a. / �Q .7�-4 Am j I Se-r✓i <br /> (LAAORAIORy or coRSOUARf) <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 /> llf ANLICADLE) <br /> OWNER/OPERATOR: <br /> (ALEASE 1`910) (111LE) <br /> 0169AIURE) <br /> ADDRESS: <br /> 1144I16 ADDRESS) <br /> (City) (SIATT) (IIP) <br /> PHONE: ( ) <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Adminisira8on Clinical Services Environmental Health Public Health Nursing <br /> 468.3400 468-3830 468 4 468.3860 <br /> Air Pollution 0ommunity Services Laoorotc WIC <br /> 466-3470 468.3820 4GB-3400 404.3260 <br />