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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br />N Crow, Pres. <br />Ead Pimento]. Vice Pres. <br />j g0� E881 Hazelton Avenue <br />San Joaquin County <br />Cly of Manteca <br />Tommy Joyce, Selly. <br />Stockton, California 95205 <br />Cly of Escelon <br />James F. Culbertson <br />Cly of Lod . <br />John D. Moa( M.D. <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />City ol Tracy <br />Virginia Mathews <br />City of Ripon <br />Thomas Schubert, D.V.M. <br />ENVIRONMENTAL HEALTH DIVISION <br />San Joaquin County <br />Daphne Shaw <br />( 209) 468-3420 <br />Cly of Stockton <br />Harvey Williams. PhD. <br />San Joaquin County <br />AUT1-1OF;1: I ZAT I ON TO FtEL_EA0IEE <br />-1104- ANALYTICAL RESULTS <br />4M- GEOTECHNICAL DATA <br />as ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />Ir THE UNDERSIGNED OWNER AND/OR OPERATOR OF TH PROPERTYjAND//pOR FACILITY <br />LOCATED AT �F_2 s 6 /�_7D <br />(S1AFE1 IIDAE��Q (C�7►)��/ <br />HEREBY AUTHORIZE P / /� -,;2/9 )-/z/ <br />4-uFCLczf-C[/C. <br />(A OAAIOAy or CDNSDLIAND STO c cam- tN(C - <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 r LAe2v U Le� <br />(IF APPLICAF ) <br />OWNER/OPERATORr <br />(PLEAS PAIN (II(LE) <br />( NAIUAE <br />ADDRESS, 172- ✓J <br />�A1lIN�N <br />(City) (STAID IIP) <br />PHONE: U <br />DATEt ,2 -/G <br />EH 23 041 Revised 1/83 <br />Administration Clinical Services Environmental Health Public Health Nursing <br />488-9400 488.3830 488-3420 488-9880 <br />Air Pollution Community Services Laboratory WIC <br />i 489-3470 488-3920 468-341,0 488-3280 <br />AIDS Information 498-3820 <br />