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r • <br /> BOARD OF TRUSTE SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> AI Cvow,Pros. <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 0.Maar,M.D. JOGI KHANNA, M.D., M.P.It., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert D.V-k ENVIRONMENTAL HEALTH DIVISIONCity of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Wllllams,PhD. LC 468-3420 San <br /> of Stockton <br /> San Joaquin County <br /> AUTHC]f;Z Z ZA-r = C3 '-r M FR E:L_EAS3E <br /> - ANALYTICAL RESULTS <br /> - GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I., THE UNDERSIGNED OWNER ANDS/OR OPERATOR OF THHT PROPERTY AND/OR FACILITY <br /> LOCATED AT �� <br /> (STREET ADDRESS) (C110 <br /> HEREBY AUTHORIZE .� � ,C-g' r'� <br /> (LAD0RA10Rr or CONSIUANI) <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 PKOVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: � � .aCa� jj✓i,�� <br /> (IF APPLICABLE) <br /> OWNER/OPERATORt T�'rr/�%'J/� <br /> PLEASE PRINT) U BLE) <br /> f'S16NAl!!RE <br /> ADDRESS: <br /> 0A1LING ADDRESS) <br /> Wrr) (SIAIE) fI1P) <br /> PHONE: 6 3 , <br /> DATE: / — 30 <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental liea,1lh Public Health Nu►sln <br /> 468-3400 8 <br /> 468-3830 <br /> 468-3420 469.3860 <br /> Air Pollutlon Community Services Laboratory WIC <br /> 460-3470 468.3820 468-3460 468-3200 , <br />