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EC',RD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT nN]� SERVING <br /> At rl im Pres. JVLZ�$ <br /> ' ulJ quin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue of Manteca <br /> Tommy Joyce,Secy. StOCktDn, California 95205 City of Escalon <br /> James F.Culbertson 5989 City of Lodi <br /> John D.Mast M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFIMAR City of Tracy <br /> Virginia Mathews TP.I HEAL1NCity of Ripon <br /> Thomas Daphne Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION CityJoaquin <br /> Couo <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AU-r C:)F< I ZA-Ir I CJ TO F2EILEASE <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OP. �OrPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT _ M.5 CiMln ryy Club Nyd• i 5-fOck-ton , +rl <br /> (STREET A RESS) , (CITY)_ <br /> HEREBY AUTHORIZE ` " ii _ nrfroflmCn (-ret <br /> 1(li ie Lo <br /> (LABORATORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> EtvVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PE'OVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> I (IE APPLICABLE) <br /> OWNER/OPERATOR: { I— fparfnQTO _ <br /> (PLEASE PRINT) (TITLE) T� <br /> �r <br /> (SIGNATURE) <br /> ADDRESS: <br /> (NAILING ADDRESS) <br /> `van `15SLeV <br /> (CITY) p (STATE) (ZIP) <br /> PHONE: (' ��� <br /> DATE: �a�f��y <br /> EH 23 041 Revised 1/8.3 <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 />