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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISj#CT <br /> Al Crow,Pres. SERVING <br /> Earl Pimentel,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.Most,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. (209) 468-3420 City of Stockton <br /> Sen Joaquin County <br /> AUTHOR I ZAT I C3N —r C3 RELEASE <br /> h ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ►t ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER, AND/OR OPERATOR OF THE PROPERTY AND/OP, FACILITY <br /> LOCATED AT ; 1, Gd i E' . 20 WA`) � O"4 Ola `3S 36 <br /> (SIREEf ADDRESS) (CITY) <br /> HEREBY AUTHORIZE C(�LIy-, ll�4Tf �R � l�nOr7fST� y@ <br /> (LAAORAIORY 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: lsc' n1 A) P� Qy <br /> (IF APPLICABLE) <br /> OWNER,/OPERATOR: <br /> fPIEA PRlYI1 �� IL 1 <br /> v L <br /> (S16NAfURE1 <br /> ADDRESS: <br /> NAIL N6 ADD S) / <br /> (CITY) (STATE) (IIP) <br /> PHONE: <br /> DATE: <br /> EH 23 041 Revised 1/83 <br /> Ad4fiinistr�n 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 <br /> 488-3280 <br /> AIDS Information 46A-3AX <br />