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B0ARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRI T <br /> AI Crow,Pros, SERVING <br /> Jaommyyarl Joyce.• Fel,Vice Pres 1601 East Hazelton Avenue �� Sen Joaquin County <br /> Secy' Stockton, California 95205 Cly of Manteca <br /> James F.Culbertson Cly of Eacalon <br /> John Most, JOGI KHANNA. M.D., M.P.114 DISTRICT HEALTH OFFICER Cly of Lodi <br /> Virginilaa Mathews <br /> Cly of Tracy <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION Cly of Ripon <br /> Daphne Shaw San Joaquin Count' <br /> Harvey Williams,Ph.O. (20':x) 46t3-3420 <br /> Cly of Stockton <br /> A U T H OF;Z I Z^T I O N -rO R S E <br /> San Joaquin County L E A <br /> -94- ANALYTICAL RESULTS <br /> 44- GEOTECHNICAL DATA <br /> -�- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OP, OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT ������i���� <br /> HEREBY AUTHORIZE (SIRE[! ADDRESS) �. �,, (Ulr) <br /> (LADVIRRIURT OP NS <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: y � �/,-77, <br /> r!F APPL1CA8lE) <br /> OWNER/OPERATOR: <br /> (PLEASE RINl (llllE) <br /> 1 R ) <br /> ADDRESS: <br /> (NAlIlNC AAD—DRESS) <br /> rclrr� rsrArE) rrrP) <br /> PHONE: <br /> DATE: <br /> EH 23 041 Revised 1/09 <br /> Administration Clinical Sorvicos <br /> 460-3400 460-0090 Environmental lie468.3420 alth Public Hoalth Nursing <br /> rsing <br /> Air Pollution bo460-9060 <br /> Community Sorvlcos Laboratory <br /> 460.3020 WIC <br /> 4�-34� 460-9200 <br /> Air"1 •,.� ... <br />