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' • • <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 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 DIVISION San Joaquin County <br /> Daphne Shaw (209) 468-3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTHOR I Z AT I MN -rO REL—EASE <br /> ANALYTICAL RESULTS <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 {�4 <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE -,^*1�c ,'ll,k` <<,,:, ,<<. a-, 1,41 etil-,a < <br /> (LABORATORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIP..ONMENTAL/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: ��"��'� �l� 21 <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: <br /> (PLEASE PRINT) (TITLE) <br /> L <br /> (S16NATURE) <br /> ADDRESS: ?Y"' -D/e-4 t L- <br /> (RAILIN6 ADDRESS) <br /> (CITY) (STATE) (ZIP) <br /> PHONE: fir' �/ .I � - C> <br /> DATE: t <br /> EH 213 041 Revised 1/139 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 488-3820 <br />