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e <br /> BOARD OF TRUSTEES SAN JOQQUfN LOCAL HEALTH DISTR]q pjNa ICounty <br /> _CounRVING <br /> Al Crow,Pros. S <br /> Earl Pimentel,vice Pros. 1601 East Hazelton Avonue CitMantecaCoty <br /> Tommy Joyce,3oo'y, Stockton, California 85205 rs^AY �} 1 ��$9 Clly o1 Escalon <br /> James F.Culbertson <br /> John D.Mael,M.D, City of Lodi <br /> �-� JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER . <br /> Virpinla Mathews ENViRON(AEN TAL 1•I_=ALT Ity of Tracy <br /> Thomas SchuborL D.V.M. ENVIRONMENTAL HEALTH DIVISION PERMIT/SE f2VlC Ity of Ripon <br /> Daphne Shaw , 2 S�i Joaquin County <br /> t;l�) +�f�a-3s.C� City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTHI©f� I ZAT I c:)IV TO fZEL.EASE <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 i (J€f ,-U ,t} { L . Lt2 <br /> (SIREEtAbDRr (City) <br /> HEREBY AUTHORIZE_ /V1 LLi2 / Com- �/1 ,� ]1j f�U <br /> (LABORATORY or CONSIIItART) <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: oEL4 , 5 <br /> (IF APPiICABtf) <br /> OWNER/OPERATOR: 5-ler M ��5 vC 1A <br /> LEASE PRINT) (ItTLE) <br /> (S Sym ) <br /> ADDRESS: / cD <br /> (RAILING ADDRESS) <br /> (City) (SIAIF) (ZIP) <br /> PHONE: <br /> DATE: 4)--�4 q : <br /> EH 23 cls}1 Revised 1/8-9 <br /> Administraflon Clinical Services Environmental Health <br /> 468-3400 468-3630Public Health Nursing <br /> 460-3420 466-3860 <br /> Air Pollution Community Services Laboratory <br /> 466-3470 408-3020WIC <br /> 406-3460 46(1-3280 <br /> AIDS Information 460-9820 <br />