Laserfiche WebLink
-§- ANALYTICAL RESULTS <br />-K- GEOTECHNICAL DATA <br />-be- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE <br />4 <br />AND/OR OPERATOR <br />OF THE PROPERTY <br />BOARD OF TRUSTEES <br />SAN JOAQUIN LOCAL HEALTH <br />DISTRICT <br />SERVING <br />• At Crow, Pres. <br />Earl Pimentel, Vice Pres, <br />1601 East Hazelton Avenue <br />San Joaquin County <br />City of Manteca <br />Tommy Joyce, Secy. <br />Stockton, California 95205 <br />City Escalo <br />James F. Culbertson <br />City <br />y of Lodi <br />John D. Mast, M.D. <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />City of Tracy <br />Virginia Mathews <br />City of Ripon <br />Thomas Schubert, D.V.M. <br />ENVIRONMENTAL HEALTH DIVISION <br />San Joaquin County <br />Daphne Shaw <br />(20 9) 468-3420 <br />City of Stockton <br />Harvey Williams, Ph.D. <br />San Joaquin County <br />AUTH©F;Z I ZAT' I ON -r0 <br />ME:L.EASE <br />-§- ANALYTICAL RESULTS <br />-K- GEOTECHNICAL DATA <br />-be- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE <br />UNDERSIGNED OWNER <br />AND/OR OPERATOR <br />OF THE PROPERTY <br />AND/OR FACILITY <br />LOCATED <br />AT �c�.Sc� <br />S:,�c�/c v'/L <br />�rjc?Gl�/� <br />—/ice/ .�',%�•C?T <br />(STREET ADDRESS) (CITY) <br />HEREBY AUTHORIZE_ ����ri%7/V% /1/6 <br />(LABORATORY or CONSOLTANT) <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: �iY,e <br />(!F APPLICABLE) <br />OWNER,/OPERATOR: _� _ c>.�t� !� -� �cN�c j� �/' �• <br />!PLEASEPRS (TITLE) <br />E <br />lSl6-� <br />ADDRESS: / . d r ASC <br />(RAILI16 ADDRESS) <br />(CITY) (STATE) (IIP) <br />PHONE: ( ) I <br />DATE: <br />EH 23 041 Revised 1/89 <br />Administration Clinical Servicos Environmental Health <br />468-3400 468-3830 468-3420 <br />Air Pollution Community Services Laboratory <br />468-3470 468-3820 468-3460 <br />AIDS Information 468-3820 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />