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AAAan ng TMISTFFS Sit JOA©UIN LOCAL HEALTH DIS ICT SERVING <br />At Crow, Pm. <br />Ead Pimentef, vice Pres. <br />1601 East Hazelton Avenue <br />San Joaquin County <br />City of Manteca <br />Tommy Joyce. Secy. <br />Stockton, California 95205 <br />City of Escalon <br />James F. Culbertson <br />City of Lodi <br />John D, Mast, M.D. <br />JOG$ KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />City of Tracy <br />Vlrginla Mathews <br />City of Ripon <br />Thomas Schubert, D.V.M. <br />ENVIRONMENTAL HEALTH DIVISION <br />San Joaquin County <br />Daphne Shaw <br />( 209) 466-3420 <br />City of Stockton <br />Harvey Williams, PhD. <br />San Joaquin County <br />t�el..�THC7� T ZAT T i=lRl Tim �iELEASE <br />-.%kl- ANALYTICAL RESULTS <br />-fart- GEOTECHNICAL DATA <br />-I-(ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT__1 2,�-6 ,�— AN 714-�/ /fO IA7-14ROP <br />(STREET ADDRESS) (CITY) <br />HEREBY AUTHORIZE- /,A l4 c�drzl�. �/,Aaa 'iLae�z -- <br />(LABORATORY or CONSU(TANT) <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:�-nU -� <br />(IF APPLICABLE) . <br />OWNER/OPERATOR: Q aJ C- r o n< /4 - <br />(PLEASE PRINT) (TITLE) <br />�Is�RTURE� <br />ADDRESS: <br />(NAILING ADDRESS) <br />,jr- N R o P CA i ?5-33 0 <br />(CITY) (STATE) (IIP) <br />PHONE: (, 0 <br />DATE: <br />L( A u a Fs9 <br />EH 23 041 Revised 1/89 <br />Administration Clinical Servicos Environmental Health <br />468-3400 468-3830 468-3420 <br />Air Pollution Community Services Laboratory <br />468-3470 468-3820 468-3460 <br />AIDS Information 468-3820 <br />Pubic Health. Nursing <br />468-3660 <br />WC <br />4G8-3280 <br />