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BOARD OF TRUSTEES A JOAQUIN LOCAL HEALTH DISTRICT ICT SERVING <br /> Al Crow,Pres, <br /> Earl Pimentel,Vice Pres, 1601 East Hazelton Avenue San Joaquin County <br /> TommyJoyce,Secy. ty of Manteca <br /> Stockton, CaliforniaC: liti95205 <br /> James F.Culbertson City of Escalon <br /> John D.Mast,M.D. City of Lodi <br /> JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews <br /> Thomas Schubert,D.V,M. ENVIRONMENTAL HEALTH DIVISION City of Ripon <br /> San Joaquin County <br /> Daphne Shaw (209) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> A�U"THOF� I ZIT" I C3 1\j TCS �ELE, SE <br /> - - ANALYTICAL RESULTS <br /> - - <br /> GEOTECHNICAL DATA <br /> 4*- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> Ir THE UNDERSIGNED OWNED AND/OR OPERATOR CIFTHE PF.'OF RTY ND/OR FACILITY <br /> LOCATED AT S � <br /> (STREET ADD R (CITY) <br /> HEREBY AUTHORIZE a,- yr . z <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: <br /> (If APPLICABLE <br /> OWNER/OPERATOR: t <br /> dAL PRI (TITLE) <br /> IN D <br /> ADDRESS-. .,, <br /> (RAIU ADDRESS) <br /> CTrY) (STATE) (ZIP) <br /> PHONE: l <br /> DATE: / <br /> f <br /> EH k? 041 Revised 1/89 <br /> Administration Clinical Servicos Environmental Health Public Hoallh Nursing <br /> 468-3400 468-3830 468-3420 469-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3290 <br /> AIDS Information 468-3820 <br />