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BOARD OF TRUSTEES *AN J0�IQUIN LOCAL • <br /> Al Crow,ares HEALTH DISTRICT SERVING <br /> !Vail Pimentel,vice Presf W <br /> 7 607 Easi Hazellort Avenue - San,loaquln County <br /> Tommy Joyce,Secy Stockton, California 95205 city or Nfanleca <br /> James F Culbertson City of Escalon <br /> John i mask t} JOGI KHANNA, M C, M P Ii, DISTRICT HEALTH OFFICER city of rLodi <br /> acy <br /> Virginia Mathews City of <br /> Thomas S&hubert,D V M ENVIRONMENTAL HEALTH DIVISION City of Ripon <br /> Daphne Shaw San Joaquin Counry <br /> Hervey Williams,PhD (209) 415,13-3-120 City or Stocklcn <br /> U`T 1-1 C:) Z Z -r Y C?t`JE "I- O Son Joaquin CDt my <br /> ANALYTICAL RESULTS <br /> - - GEOTECHNICAL DATA <br /> -�- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION I <br /> Ir THE UNDERSIGNED OWNER AND/OR OPERATOR Or THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (STREET ADDRESS) <br /> HEREBY AUTHORIZE <br /> {LAbD,PAFORY yr tt1ASJLTAJfT1 <br /> TO RELEASE_ ANY AND ALL ANALYTICAL RESULT Sr GEOTECHNICAL DAI A AND/FOR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAQUIN LOCAL HEALTF{ <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BlJb I NESS NAME• j _ -Af[ `� ; +rte ��� -- <br /> !1t AtPL1CAS ) <br /> r <br /> 'JL,NEEI/OPERATOR (PLEASE PRINT) <br /> ' <br /> (SIGRAIUK) <br /> ADDRESS: <br /> lXA1L1RG ADDR£SSJ j '--'-----------•-----.�-..�.,_,,, <br /> (CITY) {srarFr rriP, W -- <br /> l r, <br /> PHONE: <br /> DATE: <br /> 0 E ,,O 041 Revised 1/09 <br /> Administration Clinical 5ofvico3 <br /> 468-8403 4613-3800 Environmental lisam Public Hoalth Nursing <br /> 468-0420 <br /> Air Poflulion 469-x0613Community Servlcos <br /> 4611-5470 4GB-3020 Laboratory ;'Vic <br /> 4Ga-�.t&0alae-a?Bn <br /> ,AIDS inform-111nn .can ^^r <br />