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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres, <br /> Earl Plmentel,Vice Pre& 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 D.Mask M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thom"Schubert,D,V.M. ENVIRONMENTAL HEALTH DIVISION City of Ripon <br /> Daphne Shaw (209) 468-3420 San Joaquin County <br /> Harvey Williams,PhD. City of Stockton <br /> San Joaquin County <br /> AI..ATHOFi I ZAT I ON TO RELEA8E <br /> �+ ANALYTICAL RESULTS <br /> +e GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT („ I1� t_T f�lAs �T� 4 , r) <br /> (SIRE[I ADDRESS) (CITY) <br /> HEREBY AUTHORIZE Liq j3c <br /> UAD094109Y or CORSUUAN/) <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: Mpk. T r'r� t��if�/v`E►`ST r �-s-y4� <br /> OF AllllCADLE) '—' <br /> OWNER/OPERATOR: S^ nnpK') (7rA )Mr-Q <br /> (TITLE) <br /> (SI6NAIURU <br /> ADDRESS: (Q I (cJ SOl?T-td y11 P�1 N) c p r <br /> (RAILING ADDRESS) <br /> ) CA QiS33(� <br /> (CITY) (STATE) (ZIP) <br /> PHONE: Oaq) Zig <br /> DATE: Z- 3-C1 0 <br /> EH 23 041 Revised 1/0y <br /> Administration Clinical Servicos Environmental liaa;lh <br /> 466.3400 460.3090 160.9120 Public Health Nursing <br /> 169-9060 <br /> Air Pollution Community Services Laboratory <br /> 460-3470 460.9620 WIC <br /> 166-3200 <br />