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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> AI Crow,Pres. San Joaquin County <br /> Earl Plmentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sec'y. Stockton, California 85205 City of Escalon <br /> James F.Culbertson City of Lod <br /> John D.Mast,M.D. JOGI KHANNA, M.O., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathewa City of Ripon <br /> Thomas Schubert,O.V,M, ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (209) 468-3420 City of Stockton <br /> Harvey Wllliame,Ph.D. San Joaquin County <br /> A►t_. -r"0R X Z ^-T- 1 C)P4 TC3 F ELEA�3E <br /> r* ANALYTICAL RESULTS <br /> 411- GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT NJ f 1`J rt 7i0 C� - <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE LEVINE-FRICKE <br /> (thIORATORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTSr GEOTECHNICAL DATA AND/OR <br /> as required by law <br /> ENVIRONMENTAL/SITE ASSESSMENT INf=ORMATIdNTO THE SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT AS SOON AS IT IS AVAILA2LE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME; 1J RIJHGRU (A <br /> (1F APPCICAUN <br /> OWNER/OPERATOR„ t-L ajyjJ &/Z E!�' O/Z- Of= BEV <br /> LEASE PRINT) (TITLE) <br /> 1S16NATURE) <br /> ADDRESS: --7,z9- w-' M d ►2 c N L-A). S o , nff <br /> (NAR 186 ADDRESS) <br /> s-�, cry rV c S Z�7 <br /> (CITY) (STATE) (ZIP) <br /> PHONE If <br /> DATE: <br /> EH 13 Oji 1 Revised 1/8'3 <br /> Administration Clinical Services Environmental Health Public Health Nureing <br /> 468-3400 468-3830 488-3420 468-3880 <br /> Alr Pollution Community Services Laboratory WIC <br /> 4AA-3470 488-3,920 ARA-.'i460 d8A-3�po <br />