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-x- ANALYTICAL RESULTS <br />-K- GEOTECHNICAL DATA <br />-x- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />HEREBY AUTHORIZE ADDRESS) (CITY) <br />(LA80RATORY 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: <br />(IF APPLICABLE) <br />OWNER/OPERATOR: <br />(PLEASE PRINT) (TITLE) <br />0 16NATURE) <br />ADDRESS: <br />(RAILING ADDRESS) <br />(CITY) (STATE) (IIP) <br />PHONE: ( 7 <br />DATE: <br />EH 23 041 Revised 1/89 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3830 <br />Community Services <br />468-3820 <br />Environmental Health <br />468-3420 <br />Laboratory <br />468-3460 <br />AIDS Information 4611-31120 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />ON <br />0 <br />BOARD OF TRUSTEES <br />JOAQUIN LOCAL HEALTH <br />DISTRICT <br />Al Crow, Pres. <br />SERVING <br />Earl Pimentei, Vice Pres. <br />1601 East Hazelton Avenue <br />San Joaquin County <br />Tommy Joyce, Secy. <br />Stockton, California 95205 <br />City of Manteca <br />James F. Culbertson <br />City of Escalon <br />John D. Mast, M.D. <br />Virginia Mathews <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICERCity <br />of Lodi <br />City of Tracy <br />Thomas Schubert, D.V.M. <br />ENVIRONMENTAL HEALTH DIVISIONCity <br />of Ripon <br />Shaw <br />Harvey Williams, Ph.D. <br />(.t�'3 ) X6468-3420Daphne <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />U-rH0R I ZA-r I OAI TCI <br />MEI—��ASE <br />-x- ANALYTICAL RESULTS <br />-K- GEOTECHNICAL DATA <br />-x- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />HEREBY AUTHORIZE ADDRESS) (CITY) <br />(LA80RATORY 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: <br />(IF APPLICABLE) <br />OWNER/OPERATOR: <br />(PLEASE PRINT) (TITLE) <br />0 16NATURE) <br />ADDRESS: <br />(RAILING ADDRESS) <br />(CITY) (STATE) (IIP) <br />PHONE: ( 7 <br />DATE: <br />EH 23 041 Revised 1/89 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3830 <br />Community Services <br />468-3820 <br />Environmental Health <br />468-3420 <br />Laboratory <br />468-3460 <br />AIDS Information 4611-31120 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />