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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At 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.O. JOGI KHANNA, M.D., M.P.H., 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 (209) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin county <br /> A U T H O R I Z A T I O N T O Fi E L—E A 8 I=— <br /> ANALYTICAL <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> -w ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE C C-- o L„ C' ?' �'- <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 AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME �SCA.Lbr� Ute\F)�9 S��l� — Y7iSTP-kT <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: Pmc'4Aw11.— GAR-) -ADh�yrl\STRRTtJ(z .4SS15'I7ir�T _ _ <br /> (PLEASE PRINT) (TITLE) <br /> ter/ �Q C'tl� <br /> (S/6NATURE) <br /> ADDRESS: <br /> (NAILING ADDRESS) <br /> 'mss C'9 o,a r �,e . 953 <br /> (CITY) (STATE) (II?) <br /> PHONE: ( Zoq ) y33S9) <br /> DATE: < l7w / <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Heahh 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 />