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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimento],Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,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) 466-3420 �l of Stockton <br /> Harvey Williams,PhD. 'i{jl y �1y1� quin County <br /> AUTHOFz I ZAT ION TO REL 1 E •3 <br /> ANALYTICAL RESULTS 11AR 04 1991 <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL HEALTH <br /> -pf- ENVIRONMENTAL/SITE ASSESSMENT INFORI,IAA bjjERVICES <br /> I , THE UNDERSIGNED OWNER AND/OR <br /> /OPDERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT t\j I <br /> HEREBY AUTHORIZE (S1REf AD SS) (CITY) <br /> �T 2 C� el� <br /> (LAURATORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIP.ONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOA[DUIN LOCAL HEALTH <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENT. TIVE. <br /> 1 <br /> BUSINESS NAME: <br /> (IF APPLICAUL ) <br /> t <br /> OWNER/OPERATOR: �l eL w — I="— � E'rCC <br /> (PLEASE PRINT) (TITLE) <br /> (SIGNA)URE) <br /> ADDRESS: LI _ <br /> (NAILING ADDRESS) <br /> (CITY) r (STATE) (ZIP) <br /> PHONE: C�s,�j) <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental HaaOh Public Health Nursing <br /> 468.3400 468.3830 468-3420 463-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 460.3470 468.3820 468.741.10 468.3200 <br /> AIDS Information 463-3820 <br />