Laserfiche WebLink
BOARD OF TRUSTEES SAW JOAQUIN LOCAL HEALTH DISIMICT SERVING <br /> At Crow,Pros. San Joaquin County <br /> Earl Pimentel,vice Prei. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton,California 95205 <br /> Jamos F.Culbertson City City off LEoLodi Cit <br /> Jchn 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 /> AU-r"C3F;Z I Z^-r I C3M TO FZELEASEE: <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 AT <br /> (STREET ADDRES (CITY) <br /> HEREBY AUTHORIZE �0r1 /,.C!- <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:_ ( n// V! <br /> A ej 6?"? (IF APPLICABLE) <br /> P11 <br /> ;;�� G o�i5 , �JC?C� <br /> OWNER,/OPERATOR,: /l''ZiA,)&1) <br /> (PLCASE PRINT) (TITLE) <br /> (SIGNATURE) - -- <br /> ADDRESS: <br /> (NAILINO ADDRESS) <br /> (crrr) �—_ <br /> (STATE) (ZIP) <br /> PHONE: 73 <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health <br /> 468-3400 468-3830 468-3420 Public Health Nursing <br /> 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 <br /> 468-3280 <br /> AIDS Information 4GA-3820 S� <br />