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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AI Crow,Pres. SERVING <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Sac•y. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.N., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISIONCity of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. (209) 468-3420 City of Stockton <br /> San Joaquin County <br /> AUTHORIZATION TO RELEASE <br /> M ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> it ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNEGD OWNER AND/OP, OPERATOR OF THE PROPERTY AND/OP. FACILITY <br /> LOCATED AT f,'O 6 / F— Mw //U <br /> (STREET ADDRESS) (City) <br /> HEREBY AUTHORIZE Fa L�C� r/ 5 y7 <br /> (LABORATORY or CORSDLIART) I/ <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 REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (I1 APPLICABLE) <br /> OWNER/OPERATOR: C'L c a f3sL'iihQ/Z <br /> (PLEA P IRI) (T 1TlE) <br /> l C <br /> ($16NAIURE) <br /> ADDRESS: / (g3/0 <br /> (RAILING ADDRESS) <br /> -67v ee'z q 3 o <br /> (CITY) (SLATE) rttP) <br /> PHONE: 0--t9q) <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Adminis4�n Clinical Services Environmental liaaith Public Health Nursing <br /> 468-3830 468.3420 468-3860 <br /> Air Pollution Community Services Laboratory VVIC <br /> 460-3470 468-3820 468-3460 468.3200 <br /> AIDS Information 468.3820 <br />