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-K- 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 �7 � � I (� �" 1 / �< i �� � k-4 c), i, -A - <br />(STREET <br />- <br />(STREET ADDRESS) (CITY) k <br />HEREBY AUTHORIZ <br />(LABORATORY of 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: _ 1 �1I /q-1 L & U �- <br />(PLEASE PRINT) (TITLE) <br />lSISRATIIRE) <br />ADDRESS: <br />(RAILING ADDRESS) <br />(CITY) (STATE) (IIP) <br />PHONE: C ) <br />DATE: L r <br />EH 23 041 Revised 1/89 <br />Administration Clinical Servicos Environmental Health <br />468-3400 468-3830 468-3420 <br />Air Pollutlon 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 />468-3280 <br />BOARD OF TRUSTEES <br />SAN JOAOUIN LOCAL HEALTH DISTRICT <br />SERVING <br />Joaquin County <br />At Crow, Pres.San <br />1601 East Hazelton Avenge <br />City of Manteca <br />Earl Pimentel, vice Pres. <br />Tommy Joyce. Secy. <br />Stockton, California 95205 <br />City of Escalon <br />James F. Culbertson <br />John D. Mast, M.D. <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />City of Lodi <br />City of Tracy <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />ENVIRONMENTAL HEALTH DIVISION <br />City of Ripon <br />San Joaquin County <br />Daphne Shaw <br />( 209) 468—•3420 <br />City of Stockton <br />San Joaquin County <br />Harvey Williams, Ph.D. <br />AIJTHOF;Z I Z^ -r I C:) -r -r C3 FZElLEASE <br />-D- ANALYTICAL RESULTS <br />-K- 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 �7 � � I (� �" 1 / �< i �� � k-4 c), i, -A - <br />(STREET <br />- <br />(STREET ADDRESS) (CITY) k <br />HEREBY AUTHORIZ <br />(LABORATORY of 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: _ 1 �1I /q-1 L & U �- <br />(PLEASE PRINT) (TITLE) <br />lSISRATIIRE) <br />ADDRESS: <br />(RAILING ADDRESS) <br />(CITY) (STATE) (IIP) <br />PHONE: C ) <br />DATE: L r <br />EH 23 041 Revised 1/89 <br />Administration Clinical Servicos Environmental Health <br />468-3400 468-3830 468-3420 <br />Air Pollutlon 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 />468-3280 <br />