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-ft- ANALYTICAL RESULTS -K- GEOTECHNICAL DATA -k- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT-_:24!)&Oo (STREET ADDRESS) (CITY) HEREBY AUTHORIZE �e ®- (LABORATORY or CONSULTANT) TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. BUSINESS NAME: OWNER/OPERATOR: ADDRESS: (IF APPLICABLE) (PLEASE PRINT) (S161AIURE) (NAILIN6 ADDRESS) (CITY) PHONE: t s DATE: EH 23 041 Revised 1/89 (TITLE) (STATE) (IIP) Administration Clinical Services Environmental Health 468-3400 468-3830 468-3420 Air Pollution Community Services Laboratory 468.3470 468-3820 468-3460 AIDS Information 468-3820 Public Health Nursing 468-3860 WIC 468-3200 0 BOARD OF TRUSTEES . TEEs SAN JOAQUIN LOCAL HEALTH DISTRICT Ai. Crow, Pres, SERVING Earl Pimentel, Vice Pres, 1601 East Hazelton Avenue San Joaquin County Tommy Joyce, Secy. Stockton, California 95205 City of Manteca James F. Culbertson City of Escalon John D. Mast, M.D. Virginia Mathews JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi City of Tracy Thomas Schubert, D.V.M. Daphne ENVIRONMENTAL HEALTH DIVISIONCity of Ripon San Joaquin County Harvey Williams, Ph.D. 2tJ�33 X68-34� D City of Stockton San Joaquin County AIJTHO� I ZAT I Oit%.l TO F;zE:L_E-=ASit= -ft- ANALYTICAL RESULTS -K- GEOTECHNICAL DATA -k- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT-_:24!)&Oo (STREET ADDRESS) (CITY) HEREBY AUTHORIZE �e ®- (LABORATORY or CONSULTANT) TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. BUSINESS NAME: OWNER/OPERATOR: ADDRESS: (IF APPLICABLE) (PLEASE PRINT) (S161AIURE) (NAILIN6 ADDRESS) (CITY) PHONE: t s DATE: EH 23 041 Revised 1/89 (TITLE) (STATE) (IIP) Administration Clinical Services Environmental Health 468-3400 468-3830 468-3420 Air Pollution Community Services Laboratory 468.3470 468-3820 468-3460 AIDS Information 468-3820 Public Health Nursing 468-3860 WIC 468-3200