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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. Sen Joaquin County <br /> Earl Pimentel,Vice Pres, 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy, Stockton, California 95205 City of Esceion <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 SchuberL D.V.M. ENVIRONMENTAL HEALTH DIVISION Sen Joaquin County <br /> Daphne Shaw (209) 468-3420 City of Stockton <br /> Haney Williams,Ph.D. San Joaquin County <br /> AUTHOR I Z^-r I O N T O R E L E A S E <br /> 'W ANALYTICAL RESULTS <br /> i <br /> -04- GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> 0 <br /> LOCATED AT �� 0Q'z'-1 q- cS-� - P,17, <br /> (STREET ADDRESS) (C11F) /yJ <br /> HEREBY AUTHORIZE_ !) L L'b: 1 ^� �C�"✓�J <br /> (thIORAIORP or CONSULTANT) <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. <br /> BUSINESS NAME: <br /> (if APPLICABLE) <br /> OWNER/OPERATOR: RAY MA LfFN ate„ e•r <br /> (PLEAS PRINT) (TITLE) <br /> 1 <br /> (SI61ATURE111 <br /> ADDRESS: / 4f 0 g <br /> (NAILING ADDRESS) <br /> - C 9s a P <br /> (CITY) (STATE) (IIP) <br /> PHONE: (,WOQ ) 477)/77 <br /> DATE: / - ,y�)L - X9 <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Servicos Environmental Hearth Public Health Nursing <br /> 468-3400 468.3830 468-3420 468.3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3400 468.3280 <br /> AIDS Information 468.3820 <br />