Laserfiche WebLink
Administration <br />468-3400 <br />Clinical Services <br />468-3830 <br />Environmental Health <br />Public Health Nursing <br />468-3420 468-3860 <br />BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br />Al Crow. Pres. <br />Earl Pimento!, Vice Pres. <br />Tommy Joyce, Sec'y. <br />James F. Culbertson <br />John D. Mast, M.D. <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />1601 East HazeIton Avenue <br />Stockton, California 95205 <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />San Joaquin County <br />City of Manteca <br />City of Escalon <br />City of Lodi <br />City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />ONUTHOIRIZIATIMN TDIELIEONIBE <br />4.* ANALYTICAL RESULTS <br />4(- GEOTECHNICAL DATA <br />44" ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />HEREBY AUTHORI ZE <br />(LABORATORY or CONSULTANT) <br />TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNI CAL 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 />(SI6NATURE) <br />ADDRESS: <br />(NAILING ADDRESS) <br />(CITY) <br /> <br />(STATE) (ZIP) <br />PHONE: ( <br />DATE: <br />EH 23 041 Revised 1/89 <br />(STREET ADDRESS) (CITY) <br />Air Pollution Community Services Laboratory WIC <br />468-3470 <br />468-3820 <br />468-3460 <br />468-3280 <br />AIDS Information 468-3820