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BOARD OF <br /> TRUSTEES SAN JpAq,U1N <br /> a'row,Pres LOCAL HEALTH D1STR1+~T <br /> Fart Plmentel,vice Pres. 1601 East Hazelton Avenue SERVING <br /> Tommy Joyce,Secy. San Joaquin County <br /> James F.Culbertson Stockton, California 95205 <br /> John D.Mast,M.D. City of Manteca <br /> Virginia Mathews JOGI KHANNA, M.D., M.P.N., DISTRICT HEALTH OFFICER C'h' t Of Lo <br /> Thomas Schubert,D.V.M. CiCity of di <br /> Daphne Shaw ENVIRONMENTAL HEALTH DIVISION ty o[Ripon <br /> Harvey Williams,Ph.D. (209) 468- <br /> 3420 San Joaquin County <br /> A U—r C:j F;Z _ City of 5toc,.tan <br /> A T C] E L E A E3 E San Joaquin County <br /> ` - ANALYTICAL RESULTS <br /> ' - GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> Ir THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> HEREBY AUTHORIZE (STREET ADDRESS) J oG g r <br /> (Cllr) <br /> 480 y <br /> TO RELEASE ANY AND ALL ANALYTII^ALNSRESULTS , <br /> GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JO <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE S AQUIN LOCAL HEALTH <br /> TO ME OR MY REPRESENTATIVE. AME TIME IT IS PROVIDED <br /> BUSINESS NAME: <br /> (IF APP i1CABLE) <br /> OWNER/OPERATOR: X J <br /> (PLEAS PRINT) <br /> ((TILE) <br /> (S16BATURE) <br /> ADDRESS- Y <br /> (NAILIN6 ADDRESS) <br /> d <br /> (Gcrr) (STATE) (ZIP) <br /> PHONE: ( , _ 6) <br /> DATE: .� L3 y <br /> EH 23 041 Revised 1/8'9 <br /> Administration Clinical Services <br /> 468-3400 468-3830 Environmental Health Public Health Nursing <br /> 468-3420 <br /> Alr Pollution 468-3860 <br /> Community Services Laboratory <br /> 468-3470 468-3820 WIC <br /> 468-3460 468-3280 <br /> AIDS Infofmatlon 468-3820 <br />