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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> At Crow,Pres. SERVING <br /> Earl Platonist,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy <br /> James F. Ston Stockton, California 95205 City of Manteca <br /> John D.Meesh$%M.D. City of Escslon <br /> Virginia Mathews <br /> , JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> City of Tracy <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION City of Ripon <br /> Daphne Shaw (209) 468-3420 San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> AUTHOR I ZAT I ON TOR E L E A S E San Joaquin County <br /> ANRESULTS <br /> GEDTECHNICAL DATA <br /> ►t ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OP, OPERATOR OF THE PROPERTY AND/OP, FACILITY <br /> LOCATED AT . SC )u P t 1 r P <br /> (SIRIEr ADDRESS) I 5 J <br /> HEREBY AUTHORIZE LL (C <br /> 1`14809hrilff OF NS <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIP.ONMENTAL/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 REPRESENTA'rIVE. <br /> BUSINESS NAME: '{f/ <br /> (If APPIICANIE) <br /> OWNER/(OP <br /> If <br /> (P PR1N1) � � ( IIIE) <br /> (S16MAl E <br /> ADDRESS:_ /1f' V �r 0 <br /> (NAILING APPRESS) <br /> 1&l1C� V� 0/4 �j � 7 — lhU�l <br /> fCI!/) / (SIAIE) (IIP) <br /> PHONE: (I- <br /> EH 23 0141 Revised 1/09 <br /> Administration Clinical services <br /> Environmental Heath Public Health Nursing <br /> 468-3830 468-3420 <br /> 469-3860 <br /> Air Pollution <br /> Community Services <br /> 460-3470 468-3820 Laboratory WIC <br /> 468-3400 468-3280 <br /> AIDS Information 468-3820 <br />