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BOARD OF TRUSTEES S. i JOAQUIN LOCAL HEALTH Df� RICT 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 0.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 ZA'T I ON TO FRELLEA3E <br /> �+ ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> K ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER, AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 990 G/LT04 Pr/ LDo% C/ <br /> (SIRES/ ADDRESS) / C (C ) <br /> HEREBY AUTHORIZEfart?-,cJ ,o oaJsc n•i 1 <br /> (LABURRTDRy 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. l <br /> BUSINESS NAME: Sti��� S-4/0'.j —I <br /> (IF APPLICABLE) <br /> OWNER,/OPERATOR: — I& nil Cnn+o4.�tj <br /> ( L ASE P NI) (TITLE) <br /> (Sl6NA1URE) <br /> ADDRESS: _ P0, .&(7X y0L 3 <br /> (AAILIN6 ADDRESS) <br /> CC"jC0Ac, (re 7% SC y <br /> (CITY) (STATE) (ZIP) D P <br /> (j`� <br /> PHONE: C ) (z y�� li�vf 'va <br /> IV_ AN 1 <br /> DATE: ENVIRONMENTAL HEALTH <br /> PERMIT I SERVICES <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 466-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />