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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazeltor Avenue City of Manteca <br /> Tommy Joyce,Sec'y. Stockton, CafiforniEt 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 (;,09) 46-8—:342o City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AAU_rHOF' I ZAT I C3 c3 F;zEI.._EPrE3E <br /> -�- <br /> ANALYTICAL RESULTS <br /> - - <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 55-6 ee#1fM 2 A �4^ " <br /> (SIREEI ADDRESS) (CITY) <br /> HEREBY AUTHORIZE A)N 4,4d _&ld <br /> (LABORATORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTE , GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATIOh TO THE SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND eT THE SAME TIME IT IS .PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME-. ---,Ag Piodm . a <br /> Elf APPLICABLE) <br /> OWNER/OPERATOR: ._J<11,&,,,,•,,,eX r;SfiG �n{Cd <br /> (PLEASt PRINT) <br /> (TITLE) <br /> �IUIE)(SIGNA� <br /> ADDRESS: &66 Al m a P, () . Q gy <br /> (NAILING ADDRESS) Lj <br /> (CITY) (S ATE) (ZIP) <br /> PHONE: C /1) <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services =nvironmental 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- 820 <br />