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'BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DIS RIGT SERVING <br /> Al Crow,Pres. <br /> Earl Pimentel,Vice Pres, 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. 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.N., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISIONCity of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. <br /> (209) $6$-3420 City of Stockton <br /> San Joaquin County <br /> ^U-rHQF� I Z^-r I CjM -r C3 FR EL-EA0E <br /> - ANALYTICAL RESULTS <br /> - - <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT v> �j dL <br /> K- ( C)Q <br /> (STREET ADDRESS) (GITYJ <br /> HEREBY AUTHORIZE Q <br /> (LABORATORY or CONS110ANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, iGEOTECHNICAL 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 REPRESENTA'f IVE. <br /> BUSINESS NAME: fZ� _ � , {fvLJC- C til r\j <br /> (IF APPLICABLE) <br /> �� �� <br /> OWNER/OPERATOR: ¢ Nti (Z 1Crr1,�(�— r"iI�Cy- <br /> (PLEASE PRINT) (TITLE) <br /> (STGNAIORE) <br /> ADDRESS: ~� <br /> (NAILING ADDRESS) <br /> Q[ fZ i Z> +- - q-Z- 1 -7' <br /> (CITY) (STATE) (ZIP) <br /> PHONE: c 1 I o -70 0 <br /> DATE-:.- <br /> EH <br /> ATE:EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public health Nursing <br /> 468-34100 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3200 <br /> AIDS Information 463-3820 <br />