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_4A'HD OF TRUSTEES tiP JW W11V wvr+s. San Joaquin County <br /> Al crow,Pres. 1601 East Hazelton Avenue city of Manteca <br /> Earl Pimenlel,Vice Pres. Stockton,Calilornia 85205 � City of Eacalon <br /> Tommy Joyce,Secy. City of Lodi <br /> James F.Culbertson City of Tracy <br /> John D.Mast,M.D. JOGI KHANNA, 1N.0., M.P.H., DISTRICT HEALTH OFFICER City of Ripon <br /> Virginia Mathdwtt <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION San City of Stockton <br /> Daphne Shaw (209) 468-3424 San Joaquin County <br /> Harvey williams,Ph.D. <br /> AUTHOR X Z^-r I ON TO I;;ZEL.EASE <br /> - ANALYTICAL RESULTS <br /> -K- GEOTECHNICAL DATA <br /> tl- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER. )AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT S1 �7 w` ya✓6SJ <br /> (SJ EI ADDRESS) (City) <br /> HEREBY AUTHORIZE L L1 <br /> (LABORA1ORr or CONSULTAND <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 J <br /> APP�LICAILE)- Q <br /> OWNER.'/OPERATOR: 9(/7_N � ' L , �' """I�C� o w Are <br /> (PLEASE PRINT) - (TALE) <br /> (S 6NAIIlRE) <br /> ADDRESS: <br /> (NAILING ADDRESS) <br /> rcrrr) Arc) (ZIP) <br /> PHONE: c a 3 5 <br /> DATE: 7 <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 /> r <br /> 460.3470 468-3820 468-3480 488.3280 <br /> /UDS information 46R-3A20 <br /> Y <br />