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• SENVIHQ <br /> BOARD Of TRUSTEES SAN ,JOAQUIN LOCAL HEALTH DISTRICT Sen Joaquin County <br /> Al Crow,Pres. 160t East Hazelton Avenue City of Manteca <br /> ' Uri Pknentet,Vice Pre$. Stockton,California 95205 City of Escalon <br /> Tommy Joyce.Secy. Cly of Lodi <br /> James F.CulbertsonCity of Tracy <br /> John D.Most,M.D. JOQI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of nipon <br /> 'rglnlo Mathews ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> 4omos Schubert.D.V.M. Cityof Stocklon <br /> baphne Show (tog) 468-3420 San Joaquin County <br /> Harvey VVllllams,Ph.D. <br /> OFz I ZAT I Ohl TO SEI...-EASE <br /> et ANALYTICAL RESULTS <br /> +� GEOTECHNICAL DATA <br /> 40- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OP. FACILITti <br /> LOCATED AT 1 " 11 fl <br /> ( INEEI AIDtESS) <br /> HEREBY AUTHORIZE <br /> (tASORAlON1' or CONSNIIANI) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/DR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAQUIN LOCAL HEALT14 <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS Pf'OVIDI=D <br /> TO ME OR, MY REPRESENTATIVE. <br /> ITOCKTU►J UO\r 1 E17 'cjCNvoL- D 15T�Z\CT _ <br /> BUSINESS NAMEe � <br /> (If AIf1ICAalf) <br /> ASBtSToS� Np��.��"'S <br /> OWNER./OPERATORt CM-V-'L-E-5 L-�UBu�-� M/�TCQ�1/r} LS TEC-T1►Jt�-tAl� - <br /> (PEEASE MINI) (1111E) <br /> ok'6,� -- <br /> (S16NAIDAE) <br /> ADDRESS: I q 3 a- — <br /> (NA1lIN6 AIDRESS) <br /> STLX�1c 1 O� CA , Q 5)-0 5 <br /> Wry) (STAID (lit) <br /> PHONE I S�Cfl ) <br /> [D:AT:Et q - �� -Cl - <br /> EH 23 041 Revised 1/09 <br /> Administration Clinical Servicos Envlronmenlarl Ilealth Public lloallh Nui sing <br /> 169-39:10 160-3120 169-3e60 <br /> 199-9400 Community Services Laboratory WIC <br /> Alt Pollution y 169.3200 <br /> 180-3170 186-3920 106 3160 <br /> AIDS InlormsUon 166-3920 <br />