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14W swor <br /> .r <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DIST (('' 4# sERVING <br /> Al Crow,Pres. v uln County <br /> Earl Plmentel,Vice Pros, 1601 East Hazelton Avenue of Manteca <br /> Tommy Joyce,Seo'y. Stockton, California 95205 C,AY 0 1 1989 City of Escaton <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 ENV!r0NN '_NTAL HEALTH City of Rlpon <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION 'PERMIT/SERVICE0an Joaquin County <br /> Daphne Shaw ( rC l'3) 4GS-3420 City of Stockton <br /> Harvey Williams.Ph.D. San Joaquin County <br /> .4UTHC3F;Z I Z ^'T' I Mhl T© FREL—E:^E3E <br /> - - ANALYTICAL RESULTS <br /> - - GEOTECHNICAL DATA <br /> -�+- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNED; AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 'l L4 i tJ• 'J612, 0,-) . wT�l l CA 95 D. <br /> (SIREET ADDRESS) (CITY) <br /> HERESY AUTHORIZE b CrL r{�E.S L,-\j/kv T( <br /> (LABORATORY or 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: 5e$3�i I 4C-AJ I ��f-.-!U C�'�479 (K) . <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: ( t -S-1 U <br /> 'ItIASE PRINT) �^ (TITLE) <br /> IS AIBR� <br /> ADDRESS: T-5d`IC I qv <br /> (NAILING ADDRESS) <br /> d P->fz L <br /> (cITY) (STATE) (ZIP) <br /> PHONE: �.9 :► 7�5--�57 - ► 3{l <br /> DATE: <br /> EH 23 041 Revised 14/©9 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 466-3830 468-3420 468.3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Informnlion 468-1120 <br />