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BOARD OF TRUSTEES <br />A) Crow. Pres, <br />Earl Pimentel, Vice Pres. <br />Tommy Joycd, Secy. <br />James F. Culbertson <br />. ._.. -.John, O.Mast M.Dr..- <br />Virginia Mathews <br />Thomas Schubert D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />1,,WN JOAQUIN LOCAL HEALTH D%,#fRICT <br />1601 East Hazelton Avenue <br />Stockton, California 95205 <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />AUTHOR I Z^ -r I ON TO RELLEASE <br />x ANALYTICAL RESULTS <br />GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />SERVING <br />San Joaquin County <br />City of Manteca <br />City of Escalon <br />City of Lodi <br />City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin Count <br />I, THE UNDERSIGNED OWNER AND/OF.' OPERATOR OF THE PROPERTY AND/OP, FACILITY <br />LOCATED AT /i'i.�sG/_„ IL;- % � / / / . <br />HEREBY AUTHORI <br />(CITY) <br />(LABORATORY or CONSUL <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: <br />OWNER/OPERATOR: <br />ADDRESS: <br />PHONE: <br />/�•y//' (IF APPLICABLE) <br />[ �/nAA//o S Z 1� <br />(PLEASE PAIN[)) <br />(SIBNAINAE) <br />/71f 41, <br />(NAILINS ADDRESS) <br />(CITY) <br />' <br />DATE: <br />EH 23 041 Revised 1/89 <br />(711 <br />(STATE) (ZIP) <br />Administration Clinical Services Environmental Health <br />468'3400 468-3830 468-3420 <br />Air Pollution Community Services Laborelo <br />468-3470 468-3820 468-3460 <br />AIDS Information 468-3820 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />