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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 Hazelton Avenue City of Manteca <br /> Tommy Joyce,sec y. 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 t :.,C)9) 4G8-34*X2:t j City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTHOFZ I Z AT I Oh! TO FRELEASE <br /> - - ANALYTICAL RESULTS <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 1»i4A)I��-,4 <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE COiL)S ; <br /> (LABORATORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTIC_:AL 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: <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: 1 <br /> (PLEASE PRINT) (TITLE) <br /> I AIU <br /> ADDRESS: Po ��.x �� f\� <br /> (RAILIN6 ADDRESS) <br /> /�7✓7n, <br /> (CITY) (STATE) (ZIP) <br /> PHONE: L2 t� I <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 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />