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"r imubILES SAN JOAQUIN LOCAL HEALTH DICT <br />RICT E <br />- <br />AJ Crow. Prey ..-,�. <br />Ead Pimentel, Vice Pres. �./ SERVING <br />Tommy Joyce.SecY. 1601 East Hazelton Avenue San Joaquin <br />Stockton, California 95205 <br />.. James F. Culbertson Gly of Manteq <br />John D. Mast M.D. Gy of Escalon <br />Vlr Inla M JOGI KHANNA M D M PH <br />fl athews - DISTRICT HEALTH OFFICER CM of lo& <br />Thomas Schubert city ENVIRONMENTAL HEALTH DIVISION City fRipon <br />Daphne Shaw <br />ENVIRONME <br />w —City of Ripon <br />Harvey Williams, Ph.D. _ (. <a.)'dl .}L�_342iI San Joaquin County. <br />Cityo(Sbckton' <br />2.. A U T 1—i O R I Z A T I O N San Joaquin'Count– <br />TO RELEASE <br />ANALYTICAL RESULTS <br />GEOTECHNICAL DATA <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION 4' <br />rY• - <br />I, THE -UNDERSIGNED OWNED: AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT 13 To—)Al e— <br />(S77.EET A60RfSS) (CITY) <br />HEREBY AUTHORIZE V 1 C- <br />^'ll HL.L ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR- <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAQUIN LOCAL HEALTH <br />DISTRICT AS SOON AS IT IS AVAILA@LE AND AT THE SAME TIME IT IS PROVIDED A <br />TO ME OR My REPRESENTATIVE. <br />'BUSINESS NAME: %M <br />(lf RPP(ICABEU <br />OWNER/nc J4 AJZb 1 I 1 <br />_;.:".. , ✓ I Y`611A-t'e AJ 6L / /".( 4 AJ cC <br />(PLEAS' PRTl1) (TITLE) <br />N <br />(SlbAjfiURE1 <br />'ADDRESS: <br />"AILING ADDRESS) <br />(CITY) <br />PHONE: <br />DATE: <br />Clinical Services <br />EH 23 <br />041 Revised <br />1/9'3 <br />Public Health Nursing <br />/- Cd wrx-L6 -;/6 <br />W <br />(STATE) (ZIP) <br />Administration <br />Clinical Services <br />468.3400 <br />468-3830 <br />Environmental Health <br />Public Health Nursing <br />Air Pollution <br />Community Sorvicas <br />468-3420 <br />a6E-3860 <br />468-3470 <br />468-3D20 <br />Laboratory <br />WC , <br />460-]450 <br />468-3260 <br />