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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Plmentel,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.Most M.D. JOG[ 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) 46$-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> ^U-r"( F;Z I ZAT I pN -r C:11 F'ELFEE A3E <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> 44- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSI13NED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OP, FACILITY <br /> LOCATED AT 1100 West Eleventh Street Tracy, California 95376 <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE Telic Engineering Corporation <br /> !LABORATORY or CONSOLUNT) <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: The Service Station <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: _ Clyde T. Walther 02erator <br /> (PLEASE PRINT) (TITLE) <br /> t <br /> lSIGNAIUREI - <br /> ADDRESS: 1100 West Eleventh Street <br /> (N)IILING ADDRESS) <br /> Tracy, Calif. 95376 <br /> (CITY) (STATE) (IIP) <br /> PHONE: (209 ) 836-0005 <br /> %I1 1f <br /> EH 23 041 Revised 1/O'J <br /> Administration Clinical Services Environmental Heelth 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 468-3200 <br /> AIDS Information 468-3820 <br />