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P!0ARD OF TRUSTEES SAN i AQUIN LOCAL HEALTH DISTRI -T SERVING <br /> Crow,Pres. San Joaquin County <br /> l Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy, Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.il., 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 (20.3) 468-34 :0 City of Stockton <br /> Harvey Williams.Ph.D. San Joaquin County <br /> AUTHOFZ I Z ^-r I ON TO FZEL_r=-3E <br /> - - ANALYTICAL RESULTS <br /> - - GEOTECHNICAL DATA <br /> -04- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1 , THE UNDERSIGNED OWNER AN��D��/OF. OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED <br /> (STREET ADDRESS) r (CIIY) c <br /> HEREBY AUTHORIZE <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: __ / v <br /> (If APPLICABLE) <br /> OWNER/OPERATOR: <br /> (PLEASE PRINT) (TITLE) <br /> 1516NA1URE) <br /> ADDRESS: <br /> (NAILING ADDRESS) <br /> (CITY) (STATE) (ZIP) <br /> PHONE: <br /> DATE: /J�a <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Servicos Environmental lieafth Public Hoalth Nursing <br /> 468-3400 468-3830 468-3420 469-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 4GB-3280 <br /> AIDS Information 46a-3820 <br />