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BOARD OF TRUSTEES SAP) JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al 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.I ., 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 (209). 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> .aeUTHQ I ZIT I Clt\l -r C:) r<ELEP►E3E <br /> - ANALYTICAL RESULTS <br /> - - GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT �3�5 /kTLG�O � S TCjCk-r(�i,I <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE Ac-,I4ts ��.I.iIR�iJ►�I�►,J-TAL <br /> (LABORATORY or CON LTANT) <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: 6WEI -L.L- SE�ft,� STv.TIc <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: -GO 4, QIL- <br /> (P( A.SE PRINT) /" (TITLE) <br /> (SIGNAIUREI <br /> ADDRESS: �L3�o �_.�I (©�P� ; IZo✓,D 900 <br /> (MAILING ADDRESS) <br /> ILA �gSZa <br /> (CITY) (STATE) (ZIP) <br /> PHONE: SAI"S_ 7 6-76-1,j14 <br /> DATE: 4-23--91 <br /> EH 23 C)41 Revised 1/8'D <br /> Administration Clinical Services Environmental liealth Public Hoalth Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 4G8-3280 <br /> AIDS Information 468-3820 <br />