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WOO <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 /> AUTHOFR I ZAT I C3N -r C3 FZELEASE <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 1403 Country Club Blvd. Stockton <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE TARGET Environmental Services, Inc. <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: 012/L O/C. CW i-0P,4T1Q-V <br /> TIF APPLICABLE) <br /> OWNER,/OPERATOR: �i ��r `! K1. pe':e""O"o-5- 'r---.vC,r�Ec2 <br /> (PLEASE PRINT) (TITLE) <br /> 'lS Aitl�E`) <br /> ADDRESS: 38 D �'tO �Lf}i''IF A✓� S� / ZG�L� <br /> (NAILING ADDRESS) <br /> (CITY) (,STATE) (11P) <br /> PHONE: C �S/t� ) `7S'3- Z& -2— <br /> DATE: —/— <br /> DATE: Sr�T�r•, � S /9 f� �> <br /> EH 23 041 Revised 1/89 <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 />