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BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> Al Crow,Pres. SERVING <br /> Earl Pimeniel,vice Pres 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. S10Ckt011, Ca�l(Of�la 9�2d City of Manteca <br /> James F.Culbertson City of Escalon <br /> John 0.Mast.M.D. JOG[ KHANNA. M.D., M.P.H., DISTRICT HEALTH OFFICER , City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISIONCity of RiponDaphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. LCA a 468-3 20 City of Stockton <br /> San Joaquin County <br /> AU-r"MR I Z^T I aM -rQ REL E:A0E <br /> - - ANALYTICAL RESULTS <br /> - - GEOTECHNICAL DATA <br /> -+ ENVIRDNMENTAL/SITE ASSESSMENT INFORMATION <br /> 1v THE UNDERSIGNED OPERATOR OF THE Fvrmc.�- � Vi"an 2 IR9114 AC I L I TY <br /> LOCATED AT hwa 99 , c S c.k r1 <br /> (STREEI ADDRESS) (CITY) <br /> HEREBY AUTHORIZE 1�)CAeS E rr)00 <br /> ILABORAIORY at CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JDAQUIN LOCAL HEALTH <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED I <br /> TO ME OR MY REPRESENTATIVE. h <br /> i <br /> BUSINESS NAME: n USA <br /> (1f APPLICABLE) <br /> I <br /> O �G <br /> fr1 CG4 " (PLEASE PRINT) (TITLE) t <br /> SISNATURE) <br /> ADDRESS: /00 '/ <br /> i <br /> (NAILING ADDRESS) <br /> �G II/S-S- <br /> (CITY) (STAIE) (ITP) <br /> PHONE: 9 <br /> DATE: <br />