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SOARD OF TRUET114 SAN JOAQUIN LOCAL HEALTH DISTRIT SERVING <br />Al Grow. Iii �) San Joaciuln Crony <br />Earl oimemel, vice Pres. 1601 EaW Ha2ellon Avenue Cly Of A4antpon <br />Tommy Ja1Te. %WY Bluckton, Cwtornla 95205 Gy of Eacafon <br />James F. Culbertson Cly of Lodi <br />loan 0. I.tssf, M.D. JOOI KHANNA. M.O., WPM,, DISTF14T HE►LTH OFFICER Gy of Tracy <br />Virginia Mathews Cly of RIPen <br />Thomas Schuberk OVAL ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br />Daphne $haw ( 209) 468-3420 Cly of slocklon <br />Harvey wimisma, Ph.D. San Joaquin County <br />AUTHOR I ZAT I ON TO REL_aASE <br />++ ANALYTICAL RE5ULT5 <br />+r GEOTECHNICAL DATA <br />-**� ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OP. FACILITY <br />LOCATED AT -r-V -"tIq o�TOC�C <br />(S11EET A101ESS) , �lH ,/ (CITY) <br />HEREBY AUTHORIZE (ze.12iS f 00.1, <br />(1A110AAT017 or CONSOl1A10 - <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 AX6tLADLE AND AT THE SAMC TIME IT IS PROVIDED <br />TO ME OR MY REPRESENTAT <br />BUSINESS NAME: <br />OWNER/OPERA <br />ADDRESS: <br />PHONE: <br />(If Aff( <br />r (fLE SE 1A1N1) (TITLE) <br />lS16NA(OAEJ <br />(AA1(INd AAOAFSS) <br />ii -s 01/'� q s� i 7 <br />(Gill) (STATE) (11h <br />(9/6/) 37a-5-312 <br />DATEt Z7-02 / 0 <br />EH 22 041 Revised 1/89 <br />Adrr4nls"bon CYn"I Samcos Environmental Ho4hh <br />466.3400 46.3630 468.3420 <br />Air Pouuuon C,nnnwnly 3ervlce: Laowalory <br />466.3470 416.3620 406.3400 <br />AIDS Ifhferm0llOn 468-3620 <br />Pudic Health Nursing <br />A69 -sacs <br />wC <br />406-3280 <br />