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roc• 10/1=t V 11- 1a i[UbIL UIL KI�-HMUND 04053 415 235 6743 P,02 <br /> 80AR0,60 TRUSTEES SAN476AQUIN LOCAL HEALTH DISTRIG <br /> Al Crow,Pres. SEgVING <br /> FAN Pfmartlel,VIC@ rrq, 1801 East Hazelton Avenue 111�� n Joaquin County <br /> Tommy Joyce,3eo'y. Stockton, California 95205 (��1�a City Of Manteca <br /> James F.Culbanson Cly of Escalon <br /> John D.Mast M.D, JOGI KHANNA, M.D., M.P.N., DISTRICT HEA4TH V _' Eq Clhr of Lodl <br /> Vlrpinia Mathews 1 X99 City of Tracy <br /> Thomas Schubert,D.V,M, ENVIRONMENTAL HEALTH DI V I S I NSR City of Anion <br /> Daphne Shaw (209) `#68-3420 rFN�A�NiEA��+Joaquin County <br /> Hervey Williams,PhD, J�;s 5� ��� S Clly Of Stocklan <br /> �N �}2M�� � San Joaquin Count' <br /> ALJ'T'WOl� TA'y" 101V "I'"O REL.14r4£3E <br /> -rte ANALYTICAL RESULTS <br /> 40- GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/DR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 500 —":- 14/J7"LIAjE 7`�A6%r <br /> rSTREE! ADIAESS) (City) <br /> HEREBY AUTHORIZE _KAP9E4L <br /> ([410AA10ly or 00115111 1) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTSp GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN J©AQUIN 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 NAMES D-9I L OI` 45,0e p <br /> (if APP1lCA13Ei;) <br /> OWNER/OPERATOR i i4 V/0 Imo• /`IOE 'EIVVIE0 MEA1 <br /> 4� <br /> rslrcllAruai;) <br /> ADDRESS s ,9-42ALN 6 09—:- <br /> (AAIi:lS6 A�lrtifSS) _ <br /> Wry) (STAIE) (ZIP) <br /> PHONEe �3/ <br /> DATE: FE7 0(ZL�qp--rte Z2, /`�� C <br /> EH 23 041 Revioed 1/89 <br /> Adminlstretien Clinical Services Environmental Health Public Hasfth Nurssino <br /> 4U-3400 468.3m 486.9420 <br /> 4 <br /> Air Pollution Community Servlm � � C <br /> 406=34T0 aee-9680 Laboratory WIC <br /> a 66.9460 4lta-92810 <br /> TOTAL P.02 <br />