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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. <br /> Earl Pimentel,Vice Prim 1601 Last 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. City of Lodi <br /> Mast, JOGI KHANNA, M.f7,, M.P.H., DISTRICT iifU1LTH OFFICER City of Tracy <br /> Virginia Mathews <br /> Thc,rnaa Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISIONCity of Ripon <br /> Daphne Shaw San Joaquin County <br /> (Lt�'33 �i6$-3�i�D City of Stockton <br /> Harvey Williams,PhD. <br /> San Joaquin County <br /> AUTHCIR I ZA'T I 0" -r c3 �:EL_EASE <br /> -�+- ANALYTICAL RESULTS <br /> - - GEOTECHNICAL DATA <br /> -K- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/Oil FACILITY <br /> LOCATED AT -.5-e) IV, -e_L <br /> (ST�.EEI ADDRESS) _ _ —' � (Clty <br /> ) <br /> HEREBY AUTHOR ZE_, ( k�ti r �_i `, �- r4 I ✓ C n M <br /> (tRBORATORY 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 AVAILADLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> OF APPLICABLE) <br /> OWNER/OPERATOR: 41t I Id E, Ir6to w <br /> - <br /> (PLEASE PRINT) (T1 tE) <br /> f� _ -- <br /> (516N,fTN1�EJ <br /> ADDRESS. 1 <br /> (NAILING ADDRESS) <br /> (City) (STATE) (ZIP) -- <br /> PHONE: ( Vii}e) = , / <br /> DATE: ! <br /> EH 23 441 Revised 1/89 <br /> Administration Clinical Servicos Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3400 468-3280 <br /> AIDS Information 468-3820 <br />