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BOARD OF TRUSTEES • JOAQUIN LOCAL HEALTH DISTRICT <br /> Al Grow,Pres. SERVING <br /> Earl Plmentel Vice Pres, 1601 East Hazelton Avenue Sen Joaquin County <br /> Tommy Joyce,Secy. StocktonCalifornia 95205 City of Manteca <br /> , <br /> James F.Culbertson City of Escalon <br /> John D.Mast,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. <br /> (209) 468-3420 City of Stockton <br /> Sen Joaquin County <br /> AUTHORIZATION T O R E L E A S E <br /> "W ANALYTICAL RESULTS <br /> K GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER, AND/OR. OPERATOR, OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 1 c� A/ <br /> (STREET ADDRESS) - (CHY) <br /> HEREBY AUTHORIZE fir` :: r 0 r'Ti gi l o <br /> (LABORATORY 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 AVAILASLE 'AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR, MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (!F APPLlCABIE) <br /> OWNER/OPERATOR: IdP s^ 0)Pr` <br /> (PLEASE PRINT) (TITLE) <br /> (S161141URE) <br /> ADDRESS: 7 <br /> (NAILING ADDRESS) <br /> (Cl11) (STATE) (IIP) <br /> PHONE: <br /> -,.- <br /> DATE: ' I . f' - _, <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Health Nursln <br /> 468- 468-3830 468-3420 468-3860 g <br /> Air Pollution Community Services Laboratory WIC <br /> 466-3470 468-3820 468-3460 468-3280 <br /> AIDS Inlefmatlon 468-3820 <br />