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BOARD DP TRU11190 I0 SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> N Crow,Pra. Sen Joaquin County <br /> r• 'tin ow.PrN,vice Pres 1601 East Hazelton Avenue city of Manteca <br /> Tommy Joyoe,S . Stockton, California 95205 Clry of Eaoel0o <br /> ecy. <br /> James F.Culbertson Cly of Lodl <br /> Jahn D.Mss%M.O. ,1001 KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> t.:, Vlr0ln4 Moth" City of Ripon <br /> Thome Schubert.O.V.M, ENVIRONMENTAL HEALTH DIVISION Sen Joaquin County q <br /> ' Daphne Show (2o9) 468-3420 City of Stockton <br /> Hervey WIINems,per. San Joaquin County <br />' ^U-rD-MMM I ZAT I M" TO RELEASE <br /> ae ANALYTICAL RESULTS <br /> t.• +e GEOTECHNICAL DATA <br /> �e ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />` Ir THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OP. FACILITY <br /> _ LOCATED AT 1/$3 1 E• Fre maA) I <br /> (SIREEI ADDRESS) LCfl) <br /> F� HEREBY AUTHORIZE <br /> (LABORAFORY or CONSOL/ANO <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT AS SOON AS IT IS AVAILADLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> ^< BUSINESS NAMES <br /> (If A/HICABLD <br /> OWNER/OPERATOR: l� h'�/;< f'' /i�' iJt'i c �' if / 'F/ f <br /> "; OLEASE IRINI) <br /> SI6NANRE) ' <br /> ADDRESSt' `7 i / E / <br /> (RAILING ADDRESS) <br /> � ti - <br /> (City) (SIAID (IU) <br /> PHONES (-21 <br /> X <br /> DATE s <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Health Nunln0 <br /> .;$. 406.3400 468-3830 468-9420 465-3860 <br /> Air Pollution Community Services Laboratory NAC <br />�. � 460.9470 468.3820 4GS-3460 468-3200 <br /> '' AIDS Information 468-3820 <br />