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BOARD OF TRUSTEES <br />• At Crow, <br />*AN JOAOUIN LOCAL HEALTH STRICT <br />Pros. <br />C <br />Earl Pimentos, vice Pres. <br />1601 East Hazelton Avenue <br />Tommy Joyce. Secy. <br />James F. Culbertson <br />Stockton, California 95205 <br />c- ` <br />John D. Mash, M.D. f ` <br />Virginia Mathews ! , , <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />Thomas Schubert, D.V.M. n " ' <br />Daphne Shaw ! ' ; <br />ENVIRONMENTAL HEALTH DIVISION <br />Harvey Williams, Ph.D. <br />P <br />Lt,'a? 468-34;:1) <br />AUTHOM z ZA-r I OM TO REL—E:A0E: <br />- ANALYTICAL RESULTS <br />-*E- GEOTECHNICAL DATA <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />SERVING <br />San Joaquin County <br />City of Manteca <br />City of Escalon <br />City of Lodi <br />City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />I, THE UNDERSIGNED OWNER AND/OP, OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT— <br />(SIR[ 1 <br />T(SIR[1 ADDRESS) (ity) <br />HEREBY AUTHORIZE 1 <br />(1480RAtORY or CONSDiIAN[) 4 1, <br />r <br />TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOADUIN 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 />OWNER/OPERATOR: <br />Li FIL <br />(IT APPLICABLE) <br />V�eLz < <br />� PRINt) <br />(SI6IAIURE) <br />ADDRESS: tng� <br />(RAIUK6 ADORES" <br />(CITY) <br />PHONE: <br />EH 20 041 Revised 1/89 <br />(STATE) (1/P) <br />Administration Clinical Services Environmental Heafth <br />468-3400 468-3830 <br />_.e.,._ 468-3420 <br />Air Pollution Community Services Laboratory <br />460-3470 468-3820 <br />468-3460 <br />Public Hoalth Nursing <br />468-3060 <br />WIC <br />468-3200 <br />