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OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> w,Pres. San Joaquin County <br /> Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> mmy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Most.M.D. JOGI KHANNA, M.D., M.P.N., 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) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTHOFZ I ZAT I ON -r C3 FZE=LEASE <br /> >< ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> e4 ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSr�IGNED OWNER AND/OR OPERATOR OF THE PROPERTYiAND/OR FACILITY <br /> LOCATED AT A) I o <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHOR ZEA L_ t C ( ) 1— F� <br /> (LABORATORY or CONSDUARI) <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. � I Y / <br /> BUSINESS NAME s " h']f J4 ►9-" 1 L-7-0 IJ J I f1 T f 17 ,0 C' . <br /> (IF APPLICABLE) _(� <br /> OWNER/OPERATORS P —F 1 1 �U-�v ( 0 k,)-7— <br /> (PLEA IN <� (TITLE) <br /> 6NAIURE) <br /> ADDRESS <br /> (NAILING ADDRESS) <br /> �+D CA �� U <br /> (CITY)) , r �(STATE) (lit) <br /> PHONES 00 ) TSD S n <br /> C <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 468-3880 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />