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D OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> row,Pres. San Joaquin County <br /> /Thomrl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> as <br /> mmy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> mes F.Culbertson City of Lodi <br /> hn D.Mast M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> ginia Mathews City of Ripon <br /> Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> phne Shaw (209) x368-3420 Clty of Stockton <br /> rvey Williams,Ph.D. San Joaquin County <br /> AUTHOR I Z ^-r I C3" T C3 R E L-E A E3 I=— <br /> ANALYTICAL <br /> ANALYTICAL RESULTS <br /> -be- GEOTECHNICAL DATA <br /> -- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER. AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 1116 e -/fsl �/F �T �7rn'-17Dj <br /> (STREET ADDRESS) icily) <br /> HEREBY AUTHORIZE ��C{/-0l',L`/'4 /)� r� I <br /> (LABORATORY or CONSULTANT) <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: �. '4 � et i1 <br /> (6 APPLICABLE) / <br /> OWNER/OPERATOR: <br /> (PLEASE PRINT) (IIIL ) <br /> (SI61ATURE) / <br /> ADDRESS: <br /> (NAIL06 AD/DRESS) 7 <br /> (CITY) / (SIAfE) (ZIP) <br /> PHONE: (2&�rr <br /> DATE: <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 /> t 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3620 <br />