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0 0 <br />BOARD OF TRUSTEES <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />SERVING <br />Al Crow, Pres. <br />1601 East Hazelton Avenue <br />San Joaquin County <br />City of Manteca <br />Earl Pimentel, Vice Pres. <br />Tommy Joyce, Secy. <br />Stockton, California 95205 <br />City of Escalon <br />James F. Culbertson <br />Laboratory <br />City of Lodi <br />John D. Most, M.D. <br />JOGI KHANNA, M.D., M.P.N., DISTRICT HEALTH OFFICER <br />City of Tracy <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />ENVIRONMENTAL HEALTH DIVISION <br />City of Ripon <br />San Joaquin County <br />Daphne Shaw <br />( 20'3 ) 468-3420 <br />City of Stockton <br />Harvey Williams. Ph.D. <br />San Joaquin County <br />AUTHC3fR I Z^ -r I ON TO RELLEAf3FEE <br />-e- ANALYTICAL RESULTS <br />-KGEOTECHNICAL DATA <br />-w ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OP, FACILITY <br />LOCATED Al 3Pi IAI� / ��� ° ICC/ <br />ADDRESS) <br />) <br />HEREBY AUTHORIZE (Wg1S0,kx LCL "' <br />(LAa0RA10RY or CONSUL 1) <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 AVAILADLE AND AT THE SAME TIME IT IS PROVIDED <br />TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: ✓ toc(i <br />(IF APPLICABLE) <br />OWNER/OPERATOR:V /m a f 1'n v -L� <br />mu)[ PRINT) (TITLE) <br />l5f IOREiJ <br />C <br />ADDRESS: �• <br />(RAILING ADDRESS) <br />(CITY) tSIAIE) (ZIP) <br />PHONE: ( ) C9 <br />DATE: t(q 1 0, Cn <br />EH 23 041 Revised 1/E <br />Administration <br />Clinical Services <br />Environmental Haatth <br />Public Health Nursing <br />468-3400 <br />468-3830 <br />468-3420 <br />463-3860 <br />Air Pollution <br />Community Services <br />Laboratory <br />WIC <br />460.3470 <br />468.3820 <br />466-3460 <br />460-3200 <br />AIDS Information 468-3820 <br />