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� gCpvING <br /> $AN JOAQUIN LOCAL HEALTH DISTRICT" San Joagmn CD4nh <br /> DOARD Of TRNSTEes �,Ity 01 Mast°ca <br /> Al Crow,Pros. 1601 East Hazelton Avenue �.ty o:Ec,*q )n <br /> Earl Pimantel•VICa Pres. Stockton.CamorNa 95205 c;n,,,i>m <br /> TOMMY JQVCa.SsdY, Citi CI T.•=y <br /> M.O.. M.I.N., DISYRICT HEALTH OFFICER city�t 91RO6 <br /> James F.CultnRscxi .1041 t(NANNh <br /> John 0.most M.D. aan JoaOu:n CcurN <br /> wrgmlaMathew, ENVIRONMENTAL HEALTH DIVISION Cy,;i ;ocwo, <br /> 'homes Schubert.D.V.M. (209) 468-3420 San JJaQUill Courts <br /> Daphne Shaw <br /> NarveY wnuams•Ph.D. -r(a R E E_E 8 <br /> a ANALYTICAL RESULTS <br /> +w GEOTECHNICAL DATA y <br /> •ea ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> cc <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OF �A' i'-TTV <br /> LOCATED AT _ (STREET ADDRESS) rtllE) S +/ <br /> r 41"��z--��Gr GAP. �.n rca.0 <br /> HERESY AUTHOR.ZE (UDOAA►ORr o► COR UAN ) C yyi C �y063 <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEsOTECHNICAL 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 SAMC TIME IT IS PROVIDED 1 <br /> TO ME OR MY REPRESENTATIVE. <br /> I <br /> BUSINESS NAME• � �` � <br /> (lf AtfllCANIE) <br /> D f i <br /> OWNER/OPERATORSf mEASE PRINT)�PC(l�1Glf� (TIME) ar. <br /> rSTbNAiDAE) <br /> ADDRESS C < 3CC1 - <br /> (AAII(N6 ADDRESS) <br /> � 5213 - t <br /> rcun <br /> T fS1Ai[1 (ZIP) i <br /> PHONE 709 9 4 1 a'3(c <br /> DATES 2 �� �� 0 <br /> EH 23 041 Revised 1/89 <br /> ERvlronmentpl 14"Ith Public Health No:S:Gy <br /> AdminisUatlpn CIInICaI S4naoos 469.3420 469.1660 <br /> 468.3400 456-3630 <br /> I,abaatOry WiC <br /> Nr Pollution Commnmty Servleas 4611-3400 466.1200 <br /> 40-3470 4611-3520 <br />