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BOARD of TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentei,vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sec'yCulbertson <br /> Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.O., M.t?H., VISTRiCT HEALTH OFFICER City of Tracy <br /> Virginia Mathews Cary of Ripon <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (209) 468_3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTFAC3FZ I Z^-r X C3 -r C3 FZELEC..3 E <br /> - - ANALYTICAL RESULTS <br /> - - GEOTECHNICAL DATA <br /> -�- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 12751 North Thornton Road, Lodi, California <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE Whitley, Burchett & Associated, Inc. <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: ---. City of Lodi. White Slou h_ Water Pollution Control <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: Fran Forkas Water/Wastewater Sint, <br /> (TWE PRINT) (TITLE) <br /> U331 <br /> ADDFESS: Sout Ham Lane. <br /> (NAILING ADDRESS) <br /> Lodi California, 9524 <br /> (CITY) afATE) (IIP) <br /> a <br /> PHONE: < `��0.9 ) 333-6740. <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 468-3280 <br /> AIDS Information 468-3820 <br />