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BOARD,OF TRUSTEES SAN JOA4UIN LOCAL HEALTH DIST ICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,vice res. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert.D.V.M. ENVIRONMENTAL HEALTH D I V I S I DN San Joaquin County <br /> Daphne Shaw (209) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> I.J-r C:)F;Z T Z A-r I C3 -r C3 IZ E L-I—E A E3 E <br /> - - ANALYTICAL RESULTS <br /> - - <br /> GEOTECHNICAL DATA <br /> - - ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AN`D�/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT t C � Z LQ ' r-VkA 4 T)�L 0A-4�`T C ,` l� aA- <br /> (STREEI DDRESS) (CITY) <br /> HEREBY AUTHORIZE L0 Ufa iE. <br /> (LABORATORY or CONSULTANT) <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 AVAILAPLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTA'rIVE. <br /> � T 00 /,j CT1 1)[\j <br /> BUSINESS NAME: t r--P�`� <br /> (IF APPLIC48LE) <br /> OWNER/OPERATOR: 0-R--.CL�Lltof ,� _ t f Lr- <br /> (PLEASE PRINT) (TITLE) <br /> J <br /> ADDRESS: <br /> (NAILING ADDRESS) <br /> k <br /> 0 CA2�1� • ��1 3� <br /> 1�1 � '� 1 C)& , L . <br /> (CITY) (STATE) (ZIP) <br /> PHONE: <br /> DATE: F <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community ServicesLaboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />