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— S '+ L4E D 1 -4 : 1 = MCi0RE PETR10LEt_Ih1 F• <br /> P3 <br /> BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISI RICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pros. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sacy. Stockton,California 95205 City of Escalon <br /> City of Lodi <br /> James F.CulbertsonCi of Trac <br /> John 0.Mast,M 0. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br /> Cityty of Ripon <br /> Virginia Mathews <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (209) 46S-3420 City of Stockton <br /> Harvey Williams,Ph D. San Joaquin Cot:nb <br /> paUTHC7�` I ZF�`T' T C3N 'TO I�tEtL_t1=AE3E <br /> ANALYTICAL RESULTS <br /> - GEOTECHNICAL DATA <br /> -04- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR rACILITY <br /> LOCATED AT ' ?9 L YL'G,\1;L /L/C i` /),v I E,� A <br /> (STREET ADDRESS) (City) <br /> HEREBY AUTHORIZE �tjc r�� . ,, ✓,2�>,vMr�•ti�;.�+` —S ;mac . <br /> f1AdORAIORY or 60ASDt1AA1) <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 PPOVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (IF APPLICABLE) <br /> OWNED/OPERATOR: <br /> (PLEASE PR f) (TITLE) <br /> rslsNAluRE) <br /> 0AILING ADDRESS) <br /> (CITY) (STATE) (tip) <br /> PHONE t ( 20 y 3 1 7 _ <br /> DATE;: <br /> EH 23 041 Revised 1/09 <br /> Administration Clinical Servicos Environmental Health Publ'c Health Nursing <br /> 468-3400 468-3830 468-3420 469-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-0400 4f8-3200 <br /> A10S Informatlon 468-3820 <br />