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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 <br /> City of Escalo <br /> James F.Culbertson <br /> 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 (2(.-)9) 468—'34'_0 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AIJTHQFZ I Z AT I OIV TO FR E:I E=A E3 E=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 ;._, cIL c:f t?7i 7c; ; t��+T� tea. l ih �inC i I M�Vj�-Y <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE r��z2�—s�rr v�` rscH,��n� QTY rnL)C <br /> (LABORATORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTEC:HNIC-AL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFOR..MATION 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: CO AJ rc-)A,)sTO—c-c 7-0 J c `MPAlUt' <br /> _ (IF APPLICABLE) <br /> OWNER/OPERATOR: <br /> (PLEASE PRINT) (TITLE) <br /> (S16NAfURE) � <br /> ADDRESS: _ % L�pu /y531 <br /> (NAILIN6 ADDRESS) <br /> Y�1-7-5 at,T cty <br /> (CITY) (STATE) (IIP) <br /> PHONE: ( f <br /> DATE: <br /> EH 2`3 041 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 ServiCO3 Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />