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BOARD of TRUSTEES Spit JOAQUIN LOCAL HEALTH DISFtICT SERVING <br /> All 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.H., 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 /> ^U-r"CMFZ I Z AT I MM TO FRELEASE <br /> - ANALYTICAL RESULTS <br /> - - GEOTECHNICAL DATA <br /> - ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> Ir THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 1712n 6&X/ �F <br /> (STREET ADDRESS) (CIT)`) <br /> HEREBY AUTHORIZE 4 �',11dz&' 1yWd��� Can�{ruf��'u�r <br /> (LABORATORY or CONSULTANT) <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: .L�" <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: SX111 92,/ <br /> (PL E PRI A (TITLE) <br /> (SIGNATURE) <br /> ADDRESS: �4. AOS' p <br /> (RAILING ADDRESS) <br /> C^�Ca 9XJ <br /> (CITY) (STATE) (ZIP) <br /> PHONE: <br /> AUG 15 1989 <br /> DATE: <br /> ENVQONM£SERVICE l�H <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />