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80AND OF TRUSTEES <br />At Crow, Pros. <br />SA40AQUIN LOCAL HEALTH DIST(IFT <br />SERVING <br />Earl Pimentel, Vice Pres. <br />1601 East Hazellon Avenue <br />San Joaquin County <br />Tommy Joyce, Sec'y, <br />Stockton, California 95205 <br />City of Manteca <br />James F. Culbertson <br />DF/11%`L�s, <br />City of Escalon <br />John D. Mast~ M.D. <br />Vlrginia Mathews <br />JOGI KHANNA, M.D., M,P.H., DISTRICT HEALTH OFFIGE:R <br />City of Lodi <br />City of Tracy <br />Thomas Schubert, D.V.M. <br />ENVIRONMENTAL HEALTH DIVISION <br />City of Ripon <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />(205) 468-3420 <br />San Joaquin County <br />City of Slockton <br />rslsxAlxRE) <br />AU-THQFR I ZAT I ON TILT iIRELEASE <br />San Joaquin County <br />'N- ANALYTICAL RESULTS <br />-W GEOTECHNICAL DATA <br />-W ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNED AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOI ATED AT I 5 I 'l' NO, dV � ' }'q `_� <br />(SIREET ADDRESS) (CITY) ' c <br />HEF'EEiY AUTHORIZE L <br />(LABORATORY or CONSelFAND <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 />N <br />.'S <br />(IF APPLICABLE) <br />OWNER/OPERATOR: <br />G✓/j�� <br />DF/11%`L�s, <br />(PLEASE P <br />(TITLE) <br />rslsxAlxRE) <br />ADDRESS:,3900 <br />(NAILINIS ADDRESS) <br />(CITY) <br />(STAFE) <br />(IIP) <br />PHONE: <br />(209) Sal - <br />`7 EQ <br />DATE: <br />EH 23 041 Revised 1/89 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3830 <br />Community Services <br />468-3820 <br />Environmental Health <br />468-3420 <br />Laboratory <br />468-3460 <br />AIDS Information 46R.3R20 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />