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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> At Crow,Pres. SERVING <br /> Earl Pimenlel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mas(M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER Cly of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION Cly of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. (209) 468-3420 City of Stockton <br /> Sen Joaquin County <br /> A U T H O R I Z A T I MN T O R E L E A S E <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> 401- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OP, OPERATOR OF THE PROPERTY AND/OP, FACILITY <br /> LOCATED ATS 0 0 7 Lo (I ,v,,t.7 Rek �� <br /> (SiREE► ADDRESS) (CITY) <br /> HEREBY AUTHORIZE <br /> (LABORATORY or CONSOLIAMI) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIP.ONMENTAL/SITE ASSESSMENT INFORMATION TO 'THE SAN JOAOUIN LOCAL HEALTH <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTAATIVVE. <br /> BUSINESS NAME: C I\ Z( r- t e rtt acme f?r <br /> UP APPLICABLE) <br /> OWNER/OPERATOR: QTA 6,14 HG; r.a 2t 2 Fee r <br /> (PLEASE PRIN1) (IIIIE) <br /> (SI A►URE) <br /> ADDRESS: <br /> (AAfUN6 ADDRESS) <br /> (CIIY) (SIAIE) (IIP) <br /> PHONE: ( ) <br /> DATE: _ 8 <br /> EH 23 041 Revised 1/89 <br /> Admin468 13400 stration Clinical Services Environmental Health Public Health Nursing <br /> 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468.3820 468.3460 468.3200 <br /> AIDS information 468.3820 <br />