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BOARD OF TRUSTEES SAJOAQUIN LOCAL HEALTH DISOCT <br /> At Crow,Pres. , SERVING <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City or Escalon <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION City or Ripon <br /> Daphne Shaw San Joaquin County <br /> (20'3) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. <br /> San Joaquin County <br /> AUTHOFR I ZAT I ON TO (REL—EASE <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> �r ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER, AND/OP, OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT I q '5 a aZ6 (fS m't o rd 014 <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE, CALIP , WAT6K- <br /> (LABORATORY or CONSULTANT) <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:, HOGA)J x ' rG. , We- , <br /> (Ir APPLICABLE) <br /> OWNER/OPERATOR: " L �K)*4U Cn \( �) A t <br /> (PLEASE PRINT) (TITLE) <br /> nn(S16MATURE) <br /> ADDRESS: Ft)OX 399 <br /> (NAILIN6 ADDRESS) <br /> LSCA�or� Cra . 953a u <br /> (CITY) (STATE) (IIP) <br /> PHONE: (20h u38 - �3a3 <br /> DATE: / _ ( 15- O <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 <br /> 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 <br /> 468-3280 <br /> AIDS Information 46R•3920 <br />