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JF TRU8T968 SAN `AOUIN LOCAL HEALTH DISTA T SERVING <br /> ,W,Pres, — San Joaquin County <br /> Pimentel,Vice Pres, 1601 East Hazelton Avenue City of Manteca <br /> ommy Joyce,Secy, Stockton, California 95205 City of Esoolon <br /> James F.Culbertson City of lodl <br /> John D.Most M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFNICER City of Tracy <br /> Virginia Mathews Cly of Ripon <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION Sen Joaquin County <br /> Daphne Shaw (209) 468-3420 City of Stockton,,, <br /> Harvey Wllilerna,Ph.D, San Joaquin County <br /> 4- ANALYTICAL RESULTS <br /> +►+- GEOTECHNICAL DATA <br /> - ENVIRONMENTAL-/SITE ASSESSMENT INFORMATION -_-,.,�; 14 <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> L.00ATE� AT 4491 West Durham Ferry Road Tracy <br /> (SIREET hopffss) (CITY) <br /> HEREBY AUTHORIZE American Environmental Management Corporation <br /> (tA60941ORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA ANA/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFURMATYON 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. „1 • <br /> BUSINESS NAME: Ruiz Corner Grocery <br /> Y� <br /> (fj APPi1C�t9U) <br /> OWNER/OPERATOR,, Stella Ruiz Owner <br /> (PLEASE PRfNf) tflliEJ a <br /> lSt6YAfflRf) _ <br /> :4 <br /> AADfRESSr 4491 West Durham Ferry Road r tt <br /> (NAIIINO ADDRESS) <br /> Tracy CA 95376 <br /> (City) (StAff) (11P) <br /> PHONE: ( 209 ) 835-7554 <br /> DATE:., <br /> EH 23 042 Revised 1//E3'-;'/ s . <br /> Administration Clinical Services Environmental Health Publlo Health Nursln9 A <br /> 468-3400 468-3830 468-3420 ;' 488.3880 <br /> Ale Pollution Community Services laboratory WIC'' <br /> 4ae•os�o <br /> 4da-3820 466.3460 488-3280 rt <br />