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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> At Crow,Pres. SERVING <br /> Earl Pimenlel,Vice Pres, 1601 East Hazelton Avenue Sen Joaquin County <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Meat,M.D. JOGI KHANNA, M.D., M.P.11., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISIONCity of Ripon <br /> Daphne Shaw (;103) 468-3420 San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> Sen Joaquin County <br /> AIJTHOFi I ZAT I C3N TO RELEASE <br /> 'W ANALYTICAL RESULTS <br /> -110o- GEOTECHNICAL DATA <br /> -1 ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNEDOWNER AND/OR OPERATOR OF THE PROPERTY AND/OP. FACILITY <br /> // <br /> LOCATED AT.. 19 I "I �f / <br /> � L thQ� +. ca `,,��Qf1 <br /> (SIR EEI ADDRESS) o (01r) a <br /> HEREBY AUTHORIZE �-31P-n l ) � a+ICrl � , hCIC f I <br /> (LABORATORY orCONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTSr 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 /> 1-0 ML Ok MY RLPREHENI'A'rIvL. <br /> BUSINESS NAME: l7` F-YIP t w I T�C1 YI�PYI( ��� IC�VI <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: �1�1L..0. ,t <br /> (trilISE PRINT (TITLE) <br /> (ST6NAIURE) <br /> ADDRESS: —/ / 9 G . C hC? r- f e r- U Ia A4 <br /> (AAILINO ADDRESS) <br /> . CP - G���C>� <br /> (CITY) ' (STATE) (ZIP)PHONES (�C)']) 411 i Q C-- •' 99' O <br /> DATE: �JI.3�I� G <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 460-3470 466.3820 468-3460 4G8-3280 <br /> AIDS Information 468-3820 <br />