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' BOARD OF TRUSTEES #IAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres, San Joaquin County <br /> Earl Plmentel,Vita Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sec*yCulbertson <br /> 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 /> Thoma City of Ripon <br /> Mathews <br /> Themes Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (20'3) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. I San Joaquin County <br /> AUTHORIZATION TO RELEASE <br /> �114- ANALYTICAL RESULTS <br /> -W- GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNEDOWNEROWNER AND/OP, OPERATOR. OF THE PROPERTY AND/OP. FACILITY <br /> LOCATED AT �q ' joj�U Soo ' <br /> HEREBY AUTHORIZE (S1REE1 DRIES� �) WIN <br /> (EANORAIORY or CONSUUAND <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 REPREfS�E,NTATIVE. <br /> 6USINESS NAME: —IIJM��j 7J►(Mof�-f2j <br /> (IF APPLICA8LE1 <br /> OWNER./OPERATOR: <br /> (P I <br /> (lllEEl <br /> t (j U <br /> ADDRESS: �(N lLfMADDRESS) <br /> '�k / /� <br /> ( y) / /� ((SIVE) (1 _� <br /> PHONE: (��� ) Cly"lG-� — V/0�� <br /> DATE: 1 V <br /> EH 23 041 Revised 1/E39 <br /> Administration Clinical Services Envlronmenta <br /> 468-3400 468-3630 466.34: <br /> Air Pollution Community Services Laboratc <br /> 460.3470 466-3820 408-34C <br />