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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT 'VSERVING <br /> Al Crow,Pres. ��j Sahoaquin County <br /> Earl Plmentel,Vice Pres 1601 East Hazelton Avenue '� City of Manteca <br /> Tommy Joyce,Sec'y. Stockton, California 95205 s` � City of Escalon <br /> Jamas F.Culbertson IE IeB5 City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER t i _ City of Tracy <br /> Virginia Mathews v Jud- Eat+ City of Ripon <br /> Thomas Schubert D.V.M. ENVIRONMENTAL <br /> ENV I RONME } HEALTHDI V I DIVISION DN fJ <br /> Daphne Shaw v )ON, _,,VCtSan Joaquin County <br /> Haney Williams,Ph.D. ? SZ <br /> Q�R��i� I City of Stockton <br /> San Joaquin County <br /> AUTHOR I ZAT' I ON TQ F;ZEILEASE <br /> - ANALYTICAL RESULTS <br /> - GEOTECHNICAL DATA <br /> -�- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1 , THE UNDERSIGNED R OPERATOR OF THE , AC I L I TY <br /> LOCATED AT / f`}riJG, 99gnck p & �, <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE j>--, e 5 £ /T?00 <br /> (LABORATORY of 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: r1 OSA 2/5 <br /> (IF APPLICABLE) <br /> ��vrrbnn�cn�,]+ oh a 1�4 al <br /> (PLEASE PRINT) (TITLE) <br /> ADDRESS: D B6 S00 <br /> (NAILIN6 ADDRESS) <br /> RCAtn d <br /> (c[Ty) (STATE) (ZIP) <br /> PHONE: <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 46.8-3860 <br /> Air Pollution Community Services Laboratory Wic <br /> 468-3470 t - .k 14-8 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />