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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <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 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 /> AUTFiOF2I ZAT I ON TO FRELEAt3E <br /> 'x ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT__ 1100 West Eleventh Street Tracy, California 95376 <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE _ <br /> (LABORATORY or CONSDLTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIP.ONMENTAL/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. U t ti�p <br /> BUSINESS NAME: The Service Station <br /> (IF APPLICABLE) <br /> OWNERA PERATOR:)lyde I. Walther Operator <br /> (PURSE PRINT) (IIILEI <br /> SIGNAIURE) <br /> ADDRESS: 1100 West Eleventh Street <br /> (RAILING ADDRESS) <br /> Tracy, Calif. 95376 <br /> (CITY) (STATE) (IIP) <br /> PHONE: (.209 ) 836-0005 <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 /> 468-3470 468.3820 468-3460 468-3280 <br /> AIDS Information 468.3820 <br />