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• <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Prea. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Selly. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Most,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,PhD. San Joaquin County <br /> A U T H O R I Z A T I O N T O R E L E A S E <br /> ae ANALYTICAL RESULTS <br /> et GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR. OPERATOR, OF THE PROPERTY AND/OR. FACILITY <br /> LOCATED AT O-3 ,Ma%/) SfKf t 5cal ? y �4 YS-3�0 <br /> HEREBY AUTHORIZE (SIRES! ADDRESS) C4�f0)l9%d wa�yCl►Y) zarb - <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 AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: Cl7-,vOF E169LOAl <br /> � <br /> / (IF APPLICABLE) <br /> / � <br /> OWNER/OPERATOR: G/V�p lNell10/7 <br /> (PLEASE <br /> /PRINT) pe (TITLE) <br /> Y°/ .f1 ln_ <br /> ($16NAIURE) <br /> ADDRESS: - �10' 80X )qw <br /> (NAILING ADDRESS) <br /> Calm 671 953 ap <br /> (CITY) (STATE) (TU) <br /> PHONE: (,209 ) F3,i-- 3ss 6 <br /> r <br /> DATE: �C/yUSf �j /JF9 <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Sarvicos Environmental Health Public Health Nursing <br /> 468.3400 468.3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 466-3470 468-3820 468-3460 468.3200 <br /> AIDS Information 468.3820 <br />