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BOARD OF"TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT nc`�, 1�y+\f,11` SERVING <br /> Earl Pim Pres. /v�\►1 1C S +oaquin Count' <br /> Bad Pimental,vice Pres. 1601 East Hazelton Avenue ((�`[[//�� 1i. �.1 IIIUUUVVVAAhiry of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson {II A`pp )gag City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFF AQR 14 City of Tracy <br /> Virginia Mathews Nry1ESIAl NF�Ln Jo Joty of Ripon <br /> aquin County <br /> Thomas Schubert D.v.M, ENVIRONMENTAL HEALTH DIVISION <br /> Daphne Shaw C 209) 4G8-3420 ENVIRONI I SERV�C City of Stockton <br /> Harvey Williams,Ph.D. PER San Joaquin County <br /> AUTHOFZ I ZAT I ON TIO Ft�ELEASE <br /> ANALYTICAL RESULTS <br /> sf GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 33 AIA ) gii- ST 4-cm I C,n L <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE e LIF". /.t,a}i Aq-aL L.,4Rs <br /> (LABORATORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTIC_.AL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INF"ORMATION 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 REPRESEN"rATIVE. <br /> BUSINESS NAME: M• C, M . All--StoAM//Y/s <br /> c L (IF APPLICABLE) �7 <br /> OWNER/OPERATOR: ,lf(A i1 <br /> (PLEASE PR (TITLE) <br /> SI6NAIURE) <br /> ADDRESS: <br /> (R.411,IND ADDRESS) <br /> J71X Dy , L'fI S G 2 u <br /> (CITY) V (STATE) (ZIP) <br /> PHONE: (91A ) 211307/ <br /> DATE: 41/3) t`] <br /> EH 23 041 Revised 1/89 ��JJ <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468.3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3620 <br />