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BOARD OF TRUSTEES • JOAQUIN LOCAL HEALTH DISTRICT <br /> Al Crow,Pres. SERVING <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Seo'y. Stockton, California 95205 City of Manteca <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? 468-34<'i I City of Stockton <br /> San Joaquin County <br /> AUTHORIZATION T p REL E A S E <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> x ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIEiNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OP. FACILITY <br /> LOCATED AT 3y00 OA6NFK NEWTS M , S CRL7-o!J CA <br /> (STREEI ADDRESS) (CITY) <br /> HEREBY AUTHORIZE LAIN ELlE� -4- /1SSOCVIT�� <br /> (LABORAIORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTEC:HNIr_AL 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: O�(911 �>/� k4'- (-)Z) //v( <br /> (If APPLICABLE) <br /> OWNER/OPERATOR: ✓/Ll_/fl�'� <br /> (PLEASE PRINT) (TITLE) <br /> (SIGNATURE) <br /> ADDRESS: /00 <br /> (NAILING ADDRESS) <br /> (CITY) (STATE) (ZIP) <br /> PHONE: <br /> FDATE:7/ <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health <br /> 468-3400 Public Health Nursing <br /> 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services laborelory WIC <br /> 468-3470 468-3820 468-3460 <br /> 468-3280 <br /> AIDS Information 468-3820 <br />