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BOARD OF TRUSTEE! <br />AJ Crim Pres. <br />Earl Pimentel, Vice Pres. <br />'Tommy Joyce, Sec*Y. <br />James F. Culbertson <br />John D. Mast M.D. <br />Virginia Mathew3 <br />Thomas Schubert D.V.M. <br />Daphne Shaw <br />Har* Williams. Ph.D. <br />Sle JOAQUIN LOCAL HEALTH Dl IGT <br />1601 East Hazelton Avenue <br />Stockton, California 95205 <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />ENVIRONMENTAL HEALTH DIVISION <br />(*.-:`0'D) 408-342C) <br />A U -r H 0 FR 1 Z 9� -F 1 ON ?-O FR a L- E: A B a <br />z <br />San Joa <br />Citj <br />cit <br />San Joaq W'n" <br />city ors" <br />San Joaq6ii-Coni <br />ANALYTICAL RESULTS <br />GEOTECHNICAL DATA <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />U I NDERS1175NED OWNER AND/Of-, OPERATOR OF THE PROPERTY AND/OR <br />FACILITY <br />LOCATED AT <br />— <br />HEREBY AUTHORIZE <br />TO RELEASE ANY AND ALL ANALYTII--:AL R-ESULTS, 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 <br />SAME TIME IT IS P R 0 V I D E* -EY, <br />TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: a-e-L-j&z,; <br />(If APP(ICAB(E1 <br />---------- <br />OWNER/OPERATOR: t 1 4� Ci AI.Lo <br />(PLEASE PRINT) <br />(TITLE) <br />(SIG URE) <br />---ADDRESS:--- I I <br />(NAILING ADDRESS) <br />PHONE: 0q L, 1�k <br />DATE: I *L <br />EH 23 041 Revised 1/89 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3830 <br />Community "Sorlices <br />468-3820 <br />I�M;W—jm <br />R !-.L 4-" <br />(STATE) (IIP) <br />Environmental Health <br />468-3420 <br />Laboratory <br />468-3-150 <br />Public Health Nursing <br />468-3860 <br />MC <br />11. ---- <br />