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r <br /> RD OF TRUSTEES SAM`JOAOUIN LOCAL HEALTH DISTRICT SERVING <br /> ow,Pros. .� San Joaquin County <br /> Pimentel,vice Pros. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escaion <br /> James F.Culbertson City of Lodi <br /> John D.Most,M.D. JOGI KHANNA, M.D.. M.P.N., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of nipon <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (209) 468--3420 City of Stockton <br /> Haney Williams,Ph.D. San Joaquin County <br /> AU-r Fz I z^-r I ON TO r-1:lEL_0:A8E <br /> - ANALYTICAL RESULTS <br /> - GEOTECHNICAL DATA <br /> - ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OP, OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED ATId , 53 <br /> (ST T ADDRESS icily) <br /> HEREBY AUTHORIZE Lj3L I <br /> (LABORATORY or CORSILTAAT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAUUIN LOCAL HEALTH <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OF, MY REPRESENTATIVE. <br /> BUSINESS NAME: ) <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: <br /> ad 13 0 1ACi n rf-- <br /> (PLEASE PRIMT) UITLE) <br /> rs�a ArlJRE) <br /> ADDRESS: ITei <br /> T <br /> (NAILIRS ADDRESS) <br /> � r <br /> (CITY) .. (SIATE) RIP) <br /> PHONE: <br /> DATE: Z/ /Q �f <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental liaatth Public Health Nursing <br /> 468-3400 466-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory we <br /> 463-3470 468-3820 <br /> 468-34G0 468-32811 <br /> AIDS Inlormallon 468-3820 <br />