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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At 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.Most,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 (209) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> rye <br /> u-r to Cl IR I Z e4 T' I t7 h! -r c3 F:E:I EZ^!E3 IE <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 Z3Zo -I Jbrz-i A EL DO)?at'z>o <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE �OhIONIE <br /> (LABORAIORY 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 ITIS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: SHrELL SElht► s i 'H Ul, <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: -LL. c>rl CoMP,A <br /> (PL A.SE PRINT) (TITLE) <br /> - .•" � .`•L�-rte ' <br /> (S16NA7URE) - <br /> ADDRESS.: _ 'I l�li ICc�w ���s l;� 4�1zt- 90b <br /> (MAILING AODRESS) <br /> (CITY) (STA1E) (IIP) : <br /> PHONE: ( QTS) (0-7(0 <br /> DATE: �7 <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Servicos Environmental Health Public Hoalth 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 />