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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.M., 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 ( '2 9) 4E,8 -342f) City of Stockton <br />Harvey Williams, Ph.D. San Joaquin County <br />A4_. "r"C)F;� 2 Z AT I 0 N -rO FR a L_ E: A E3 a <br />-W ANALYTICAL RESULTS <br />-w- GEOTECHNICAL DATA <br />-pt- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER ASVD/OR OPERATOR: OF THE PROPERTY AND/OR FACILITY <br />n <br />LOCATED AT <br />(STREET ADDRESS) (CITY) <br />HEREBY AUTHORIZE <br />(LABORATORY or CONSULTANT) <br />TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTEI­_:HN I CAL DATA AND/OR <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAQUIN LOCAL HEALTH <br />DISTRICT AS 'SOON AS 17' IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br />TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME- zz 5 ac,+rcar.l 7G ✓��•E <br />(IF APPLICABLE) <br />+f -- <br />OWNER/OPERATOR: w'`{'r <br />_- �!BillI-L <br />(PLEASEJ/PRINT) , (TITLE) <br />'4 4 <br />---------------- <br />(SIGNATURE) <br />ADDRESS: �- 1 �t t'_ �J. c4t,Fae-l".) <br />(MAILING ADDRESS) <br />(CITY) (STATE) (IIP) <br />DATE=: ////'aIT.r,C, <br />EH z0 041 Revised 1/89 <br />Administration Clinical Services Environmental Health <br />468-3400 468-3830 468-3420 <br />Air Pollution Community Services Laboratory <br />468-3470 468-3820 468-3460 <br />AIDS Information 468-3820 <br />Public Health Nursing <br />468-3860 <br />WIC <br />466-3280 <br />