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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> At Crow,Pres. SERVING <br /> Earl Pimentel,Vice Pres, 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mas(,M.O. JOGI KHANNA, M.D., MP-14., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION City of Ripon <br /> Daphne Shaw ('[09) 468-3420 San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> San Joaquin County <br /> A U T H O Fac I Z A T I O N T O R E L E A S E <br /> x ANALYTICAL RESULTS <br /> ac- GEOTECHNICAL DATA <br /> -+t' ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OP, OPERATOR, OF THE PROPERTY AND/OP, FACILITY <br /> LOCATED AT 4�&C4v5' Al 14'4 0,1Alie- zl) Z2729 ,�J C�4 <br /> (SIREEI DDRESS) ' <br /> (CITY) ' <br /> HEREBY AUTHORIZE `L P, ZL e <br /> (LABORATO Y of CORSO(IANf) <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: G l.c/l9l— <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: NC <br /> ,(PLEASE P ) (T1l(f) <br /> (S16RATURE) <br /> ADDRESS: 11012 ,c/ ,Q�,��piJ : <br /> (SAILING ADDRESS) <br /> (CITY) (STATE) (IIP) <br /> PHONE: 4421 ) <br /> DATE: <br /> EH 23 041 Revised 1/83 <br /> Adminislration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400468-3830 468-3420 468-3860 <br /> Air Pollution Community Services laboratory WIC <br /> 468-3470 468-3820 468-3460 <br /> 468-3280 <br /> AIDS information 468-3820 <br />