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HOARD OF TRUSTEES <br />Al Crow. Pres. <br />'Earl Pimentel, Vice Pres. <br />Tommy Joyce. Sec'y. <br />James F. Culbertson <br />John D. Mast, M.D. <br />Virginia Mathews <br />Thomas Schubert D.V.M. <br />Daphne Shaw <br />Harvey Williams, PhD. <br />CP <br />SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br />1601 East Hazelton Avenue =a San Joaquin county <br />City of Manteca <br />Stockton, California 95205% City of Escalon <br />City Of Lodi <br />JOGI KHANNA. M.D.. M.P.1f, DISTRICT HEALTH OFFbC}R City of Tracy <br />City of Ripon <br />ENVIRONMENTAL HEALTH DIVISION.,'-", Sakdoaquin County <br />( 20'3) 468-3420 `: ` w �; City,.of Stockton <br />'`•0l {iy<� % Salt Joaquin County <br />AUTHOR S ZAT S ®N 'T® <br />- ANALYTICAL RESULTS . <br />.� <br />-x- GEOTECHNICAL DATA <br />-m- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT 601 L -t -A . .. L_®P I <br />(STREET ADDRESS) (City) <br />HEREBY AUTHORIZE KA�kEALIAiJ F�n1G tN��i<.�NG ,.� h%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 AVAILAOLE AND AT THE SAME TIME IT IS PROVIDED <br />TO ME OR MY REPRESENTATIVE. <br />�SUSINESS NAME: <br />(IF APPLICABLE) ' <br />OWNER/OPERATOR: .Ut A\ON Oki-. ) <br />(PL-E�ASE PRINT) (TITLE) <br />iS16NATURFj <br />ADDRESS: 2-000 LRaW CAN`(0tQ 4-0 I <br />(NAILING ADDRESS) <br />'S'�N szAMON GA q '�-� es <br />(CITY) I(STATE) (W) <br />PHONE: (447)&,77-0776,0 <br />DATE: <br />EH 23 041 Revised 1/89 <br />Administration <br />Clinical Services <br />468-3400 <br />468-3830 <br />Air Pollution <br />Community Services <br />468-3470 <br />463-3820 <br />Environmental Health <br />468-3420 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468.3860 <br />WIC <br />468-3280 <br />I <br />