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BOARD OF TRUSTEES SAJOAQUIN LOCAL HEALTH DIST SERVING <br /> At Craw,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1501 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. JOCI KHANNA, M.D., M,P.H., DISTRICT HEALTH OFFICER' City of Tracy. <br /> Virginia Methews City of Ripon <br /> Thomas Schubert.D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (209) 468-34217 City of Slocklon <br /> Harvey Williams,PhD. San Joaquin County <br /> AUTHC]R I Z^—r 10" TC) FRE!—E�►`3E <br /> - ANALYTICAL RESULTS <br /> - GEOTECHNICAL DATA <br /> -�- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PRO ERTY AND/OR 'FACILITY <br /> LOCATED AT <br /> (STREET ACaRE ) (�llY <br /> /71 <br /> HEREBY AUTHORIZE f� � Tc—� /11 <br /> (LABORATORY or CONSOLTART) <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 /> SUSINESS NAME: Jr. � yP�l/GAS <br /> (!F APPLICABLE) <br /> OWNER/OPERATOR: 1S~ <br /> (TITLE) <br /> (sraxATURE) �� - <br /> ,, i <br /> ADDRESS• ---' <br /> (Ahltag ADDRESS) <br /> (CITY) (SLATE) (IIP) <br /> PHONE: (fid ) 9 <br /> DATE: <br /> EH 3 041 Revised 1/09 <br /> Administration Clinical Services. Environmental lieallh Public Health Nursing <br /> 468-3400 466-3830 468-3424 463-3860 <br /> Air Pollution Community Services laboratory WIC <br /> 468-3470 468-3820 408-3460 408-3200 <br /> AiD3:nform,lt-}n 463.3820 <br />