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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <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 (2o,3) 468-342*t City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> ^LJ-r C3FZ I ZAT I C3" 'i'O FZEiLEASE <br /> •04- ANALYTICAL RESULTS <br /> -04- GEOTECHNICAL DATA <br /> -1►� ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OFT THE PROPERTY AND/OR FACILITY <br /> LOCATED AT '� 41e.5+ L 1"1 � <br /> � . Rd r rcicy <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE___ kcG� G. Vj"S+.,, Stec <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: �YI. )e- v F u.c-.c_ <br /> (IF APPLICABLE) <br /> OWNER,/OPERATOR: <br /> 7-1 <br /> ARINi) (TITLE) <br /> 1, SIGNATURE) (� <br /> ADDRESS: J P O <br /> (NAILING ADDRESS) <br /> (CITY) (STATE) (� <br /> PHONE: ( 2-Cf ) S _ S�Z 3 <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 />