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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 <br /> City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 R E C E I V E City of Escalon <br /> James F.Culbertson n City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER DEC `'a 1989 City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH DIVISION ._. (� San Joaquin County <br /> Daphne Shaw (20'3) 468-34:'0 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AUTHOR I ZAT ION TO f:E1 EAE3E <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_ `�9"r r /Y/' L";'j <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE /'/�itlOni/� /�ti)lL� iJM,��c�7�L J'�i2Vi f1S' C�Dy?/'�,Ps47G <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 AVAILADLE AND AT THE SAME TIME IT IS PF'OVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (11 APPLICABLE) <br /> OWNER/OPERATOR: ��i�rr� j c-S '"e— <br /> (PLEASE PRINT) (TITLE) <br /> c�lSIGNAI.UREI � <br /> ADDRESS: c 42 .-1 /y c' -7 <br /> (NAILING ADDRESS) <br /> -V,lL i <br /> (CITY) (STATE) (ZIP) <br /> PHONE: ( '1 ' , <br /> DATE: /Z — 12 <br /> EH 23 041 Revised 1/09 <br /> Administration Clinical Services Environmental Itaa;th Public Health Nursing <br /> 468-3400 468-3830 468-3420 463-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-34GO 468-3280 <br /> AIDS Information 463-3820 <br />