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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTPICT SERVING <br /> At Crow,Pros. <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue "' Sen Joaquin County <br /> Gy of Manteca <br /> Tommy Joyce,sey. Stockton,California 95205 City of Escalon <br /> James F.Culbertson y. <br /> of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews Cly of Ripon <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (209) 468-3420 Cly of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTHOR I z^*r I ON TO RELEASE <br /> +a ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> M ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY G <br /> LOCATED AT_ / CO J A)Q bI S T 1A L I�V r�TTI IC TO/�I <br /> HEREBY AUTHORIZE <br /> (STREET ADDRESS) (CITY) <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: V/V/ 'V /e <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR.: <br /> (PLEASE PRINT) (TITLE) <br /> l <br /> 4n'S/6NATUAE) <br /> ADDRESS: ! <br /> (NAIL/16 ADDRESS) <br /> �TDciCronl ( aoti <br /> (CITY) (STATE) (ZIP) <br /> PHONE: (0?09 ) 9 00 <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Hedth Nursing <br /> 468.9400 469-3870 468-3420 468-38W <br /> Air Pollution, Community Services Laboratory VVIC <br /> 468-3470 468.3620 468-3460 468-3280 <br /> AIDS Information 4611-31120 <br /> lo)'? <br />