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R' 116A110 Of teUtTEEa <br />At Crew, Plea. <br />�S iMf Plawnho. vice Pros. <br />9'emmy Jem. Secy. <br />Jatswe F. Culherbon <br />John D. Meal, M.D. <br />f I.lrainle Mathews <br />1!� mom Schubert DY.M <br />S Ylaphna $hew <br />Harvey Williams, Ph.D. <br />s' <br />Y <br />a <br />sERVINO <br />SAN JO' 1UIN LOCAL HEALTH DISTRICT San Joaquin County <br />City of Manteca <br />trot East Hazelton Avenue city of Faction <br />Stocklon, Calllorrlla 95205 City of Lodi <br />City of T,ecy <br />JOOI KHANNA, M.D., M.►.11, 0IaTa1CT HEALTH OFPI'CEn City or ninon <br />San Joaquin County <br />ENVIRONMENTAL HEALTH DIVISION City of slocwton <br />( 209) 468-3420 San Joaquin County <br />AlJ7h10R I ZA A I CSN 'T-" MELM^MM <br />4+ ANALYTICAL RESULTS <br />44. GEOTECHNICAL DATA <br />.w ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />t I, THE UNDERSIGNED OWNER AND/OP. OP OF THE PROPERTY AND/OP. FACILITY <br />_l._TiVG TCS sk r �l'T_.=. <br />LOCATED AT o!�J " G� " VAS <br />L <br />(STREET AI/RESP) _ <br />HEREBY AUTHORIZE 1G`(IAIORATORE o COASI(IAAI1 <br />TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOADUIN LOCAL HEALTH <br />biSTRICT 115 SOON 115 IT iS AVAILABLE AND AT THE SAME TIME IT I5 PROVIDED <br />I <br />TO ME OR MY REPRESENTA'EIVE. <br />)USINESS NAME1 <br />TOCK -Co" U)3li FfiLD ` <br />D ►STR\C-T <br />(IT ANUCAItt) ASBc5To5/ T-iA2- 4V-D0v5 <br />IWNER/OPEP.ATORI G"A-.L-E-S LCLA39E-P� F�t�hTE�lI4LS "FFl-t1ti►1CLp`F-� <br />(111115[ PRINT) (Tilt() <br />(SISAAIIAEI <br />AbDPESSt 1131 E� �iNlq <br />(RAIt1A1 AIORESS) <br />9sa05 <br />(CITY) (STATE) (i11) <br />PHONEt . M 9-9 - g 09 8 - <br />DATEt q'X(o'"1U <br />EH 23 041 Revised t/09 <br />Adminlsttallon <br />4 i 4M-9400 <br />Al, Ponuoon <br />488-3470 <br />Clinical so"Icoe <br />466-3890 <br />Community Services <br />4863820 <br />Environmental I laellh <br />468-3420 <br />laboratory <br />468-3400 <br />AIDS Information 468-3820 <br />Public lloalth Nu,smil <br />469-9860 <br />—w6-- <br />468 3211 <br />yir4683280 <br />