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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,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.Mast,M.D. JOGI 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) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTHOR I Z A T I C31s4 T O R E L E A S E <br /> ANALYTICAL RESULTS <br /> s4 GEOTECHNICAL DATA <br /> -w- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER, AND/OR OPERATOR. OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 70l' /N v1A rr-14-L ?PtR-),-- DQ► V f=- AlT j c �� gs33 <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE R 'y k'/✓C LII g O1L�9 7 G,�/ <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: <br /> (IT APPLICABLE) <br /> OWNER./OPERATOR: 4-12, S H4L.L- 1=H rZ- — `UW N (_,� <br /> (PLE�ASEnPRINT) <br /> , (TITLE) <br /> � `/ <br /> (S1611A1 RE) <br /> ADDRESS: 5-25- LI-HQ P4P9-GE <br /> (NAILING ADDRESS) <br /> VY1 i4M �-cy}- C �I- �yJ'33C <br /> (Cllr) (STATE) (ZIP) <br /> PHONE: (ZJ'% <br /> DATE: <br /> EH 23 D41 Rev sed 1/89 d <br /> Administration Clinical Services Environmental Health Public Health Nursin <br /> 468-3400 468-3830 468-3420 468-3860 g <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468.3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />