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• BOARD OF TRUSTEES SACOAQUIN LOCAL HEALTH DIS•CT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimentel,vice Pres. 1601 East Hazelton Avenue Cory Manteca <br /> Joaquin <br /> M <br /> Tommy Joyce,sec'y. Stockton, California 95205 city or anteca <br /> James F.Culbertson Cif or Lodi <br /> scalon <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw ('2 i9) 468-342o City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> ALJTHOF2I ZAT I ON TO FREILEASE <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OP. OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT �DO ��'✓IC(/I��( !O�/�ty(ol 4a6"a�" � � CJ; na gSZO2 <br /> (STREET 'T' 3SS)//// �— (City) <br /> HEREBY AUTHORIZE I , H • KC(Qvr �OY <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: <br /> (IF APPLIC'AJBL/E) �� [ r <br /> OWNER,/OPERATOR: (J `/ v C G/1O(J' L��n L Q <br /> (PLEASE PRIM[) (TITLE) <br /> t,1A <br /> (SIGNATURE) <br /> ADDRESS: L}2 , O V� <br /> (RAILING ABORESS) <br /> (CITY) (STATE) (ZIP) <br /> PHONE: ( I <br /> DATE: <br /> EH 23 041 Revised 1/89 <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 <br /> 468-3260 <br /> AIDS Information 460-3820 <br />