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BOARD OF TRUSTEES S JOAOUIN LOCAL HEALTH DIS R(C;T <br /> Al„row,Pros, SERVING <br /> 'Tommy <br /> Carl yel,vice Pres 1601 East Hazelton Avenue �� Son Joaquin County <br /> Joyce,Secy. - <br /> James F.Culbertson Stockton, California 95205 City of Manteca <br /> John D.Mast,M.D. City of Escalon <br /> Virginia Mathews JOGI KHANNA. M.D., M.P.Ii., DISTRICT HEALTH OFFICER City of Lodl <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION Cit'of Tracy <br /> Daphno Show City of Ripon <br /> Honey Williams,ph.D. (209) 468-3420 Son Joaquin County <br /> City of Stockton <br /> A U`r'F-10 Ft Z z A"i' I O N San Joaquin Count' <br /> T O R E L E A S E <br /> 44- 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 <br /> HEREBY AUTHORIZE lSlRCfI ADDRESSI r � � (ClIl1 <br /> TO RELEASE ANY AND ALL ANALYTICALNSRESULTS, GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JO AND/OR <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SA AQUIN LOCAL HEALTH <br /> MC TIME IT IS PF;OVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: " <br /> flF APPUCADI[) <br /> OWNER/OPERATOR: ] <br /> lP1fASE RIM! (lllL[J <br /> ADDRESS: <br /> (BAIIlNG AODR[SSJ <br /> IS <br /> t'CIlPI fSiBfEj f71P) <br /> PHONE: <br /> DATE: <br /> EH 041 Revised 1/09 <br /> Administration Clinical Servicos <br /> 468-3400 460-3030 Envlronmental iieafth Public Hoalth Nursing <br /> Air Pollution 468-3420 460-3060 <br /> 460-3470 Community Services Laboratory <br /> 460-3020 WIC <br /> 4G0-3460 . <br /> 4G0-17nn <br />