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SAN JOAW IN LOCAL HLALIH DISIRILI <br /> Environmental Health Division <br /> 1601 E. Hazelton Ave .., P.O. Box 2009 <br /> Stockton, CA 95201 <br /> (209) 466-6781 <br /> FIRM NAME I�N s Di��rib�f)NO COfiCbNU <br /> ADDRESS ,i 3 20 Gt/ Gt/r�Pr <br /> As authorized by the California Health and Safety Code, Division 22, Chapter 4, Article 4, <br /> the following action is being taken: <br /> ❑ OFFICIAL SAMPLE RECEIPT: The items listed below were collected as official samples on <br /> this date as authorized by Section 27560. DATE <br /> C] VOLUNTARY CONDEMNATION & DESTRUCTION: I(We) hereby voluntarily agree to the <br /> condemnation and destruction of the following item(s) and release the Health District <br /> and its agents from any and all liability regarding the agreed upon VC&D. <br /> METHOD of DESTRUCTION: <br /> DATE <br /> E0 IMPOUND NOTICE: You are hereby notified that the following item(s) is/are impounded <br /> under the provisions of. Section 27561. DATE g//Xe/Ze <br /> [ IMPOUND RELEASE: You are hereby notified that the following impounded item(s) is/are <br /> released under the provisions of Section 27561. DATE <br /> 12 442hlrz�mna <br /> -� C n.¢acT.uO ✓o%.v Ss/rn� rr/«.Y. �f f Qr� Sr ?ur�etcfe� /�e shnTi./a// �� ��t„^s �l,+�Dou <br /> Quantity Units Item Description Location I.D.p Released Date <br /> and Initials <br /> 41� S ,V G✓GYnP`,0 SC G✓'nP/°c IjW alVECf -eleeefAe- <br /> d U�/ <br /> ORDER BY � � ACKNOWLEDGED BY Q" <br /> Sanitarian Firm Representative <br /> CoQ _ y>58� 3yy� <br /> -EH 01 15 <br />