Laserfiche WebLink
BOARD OF TRUSTEES S 1 JOAQUIN LOCAL HEALTH DISTRICT SEWING <br /> San Joaquin County <br /> Al Crow,Pres. 1601 East Hazelton Avenue City of Manteca <br /> Earl Pimentel,Vice Pres. Ci of Escalon <br /> Tommy Joyce,Secy. Stockton,California 95205 City <br /> City of Lodi <br /> James F.Culbertson <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.M., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia MathewsCity 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 /> AI.JTHC)F;Z I ZAT I C3 TO f El,_EASI=— <br /> ANALYTICAL <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 b <br /> (ST Er ADDRESS) (CITY) <br /> HEREBY AUTHORIZE <br /> (LABORATORY or CONSOLTANT) <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: eez d Tra le�,5 <br /> w/ (IF APPLICABLE) <br /> OWNER./OPERATOR: erre- e, 7-a- Z Ci-d �f.¢✓ ' <br /> (PLEASE PRINT) (TITLE) <br /> (S16NATURE) p , <br /> ADDRESS: m&z: ZjeL a -�-✓`— <br /> (RAILIN6 ADDRESS) <br /> (CITY) (STATE) (ZIP) <br /> PHONE: <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Health 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 /> AIDS Information 468-3820 <br />