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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALADISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel.Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,sac'y. Stockton, California 95205 City of Esc.slon <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 DIVISION San Joaquin County <br /> Daphne Shaw (209) 468-3422 •City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> ,ch u- "HQFR:1 ZA,T 2 C7 -F(D r<I:LEA E3 FE <br /> 4t ANALYT I CAL• RESULTS <br /> •X• GEOTECHNICAL DATA <br /> - - ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR :OPERATOR OF THE PROPERTY AND/OR -FACILITY <br /> LOCATED AT kn' MAIO S'T R-aS—r �.W-r <br /> (STREET ADDRESS (G11Y) <br /> HEREBY AUTHORIZE - --�1c� U=� <br /> UASORADRY or caKsrlLTAKr)� <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 PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: '---H E� L-L SF, I 1 C� <br /> (IF APPtICAU E) <br /> OWNER/OPERATOR: 'Si E� L-t-- C) - t-� <br /> (Pt ASE PP,IKT) (TITLE) <br /> ADDRESS: <br /> (XAILfKG Ac DRESS) <br /> (CITY) (VALE) (Z 1P) <br /> PHONE: (41 S ) r7_ i L} E <br /> DATE: jjl 6/9i <br /> EH 23 041 Revised 1/89 <br /> Adrminlstratlon Clinicol Serricos Environmental Iiae:th Public Hoalth Nursing <br /> 468-3400 468-3830 468-3420 468-3660 <br /> A1r Pollution Community Services Laboratory WIC <br /> ,68-3470 468-3829 468-34W AC8-3280 <br /> A10S Informotlon 46a-3820 <br />