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eaiRO OF tRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> A]Crow,Pros. San Joaquin County <br /> Earl Plmentel,vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce.Socv - Stockton,Callfomia 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.11., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews I City of Ripon <br /> Thomas Schubert,o v,1d. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Show (209) 468-3420 City of Stockton <br /> Harvey Wiiliems,Ph.D. San Joaquin County <br /> AUTHOR I ZAT I ON `TO RELEASE <br /> -W 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 <br /> (SIREEF ADDRESS) WIT) <br /> HEREBY AUTHORI ZEJ t - 60 'f;C ' g <br /> 1 (LARRAIVAT or C4NSOLFANO <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAQUIN LOCAL HEALTH <br /> DISTRIiCT AS SOON AS IT IS AVAILAPLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAMEs - _ &W I PAI ZCdE <br /> (IF AIILICAALE) <br /> OWNER/OPERATOR: d A) IDE41ir <br /> (tL R.S RINI. <br /> ) (1 r 1 <br /> (sraNAr F) <br /> ' L I <br /> ADDRESS: --' <br /> (NAiLIN6 ADDRESSI <br /> Loi Aa►�ra€�—� ,r—�, ..,_____�m�a� __._.,. .., <br /> (Crrr) (SIArf) (ZIP) <br /> PHONE s t ` ? — I <br /> DATE: ,z r i <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Servlon Environmental lloelth public Health Nursing <br /> 466-3400 466-3830 468-3420 468.3860 <br /> Air Pollution Community Services Laboratory we <br /> 460-3470 468-3620 408.3400 408-3200 <br /> AIDS Informailon 468-382n <br />