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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH D I 1 SERVING] 1 <br /> Crow,Pres. <br /> E San Joaquin County© <br /> Earl Pimentel,vice Pres. 1601 East Hazelton Avenue � � City of Manteca <br /> Tommy Joyce,Sac'yCulbertson <br /> Stockton, California 95205 ���°AA City of Escalon i <br /> James F.Culbertson C 1989 City of Lodi <br /> John D.Mast,M.O. JOGS KHANNA, M.D., M.P.H., DISTRICT HEALTH OFF Clty of Tracy <br /> Virginia Mathews I CI of RI on <br /> Thomas Schubar%D.V.M. ENVIRONMENTAL HEALTH D I V I%.JJU 1 O WIEs J T AL HEALT H San Joaquin County <br /> Daphne Shaw (2(.'19) 4 60-��3420 PERMIT 1 SERVICES Joaquin <br /> u n County <br /> Harvoy Williams,Ph.D. Citykton <br /> San Joaquin County <br /> ^U-rHC3FZ I ZAT I Ohl TGA MELEAV3E + <br /> i <br /> 4+ ANALYTICAL RESULTS ! <br /> I <br /> - - GEOTECHNICAL DATA <br /> -b- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1 , THE UNDERSIGNED OWNEI;' AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT �[1 <br /> cSTREfr ADDRESS (City) <br /> HEREBY AUTHORIZE-- Y �1/�- z�j e , <br /> (LABORATORY or CONSNLTANT) <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 /> 1 <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (if APPLICADLE) <br /> OWNER/OPERATOR: <br /> LEASE PRINT} rrrrLE): f <br /> (S G IUR } <br /> ADDRESS: 1 q D <br /> ( AILING ADDRESS) <br /> (City) (SrATE) 7I1P} <br /> PHONE: ( ► �� — l 3 l i <br /> DATE: e <br /> EH 23 041 Revised 1/89 � <br /> I <br /> Administration Clinical Services Environmental Health PublIc'Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-382.0 461)-34G0 468-3280 <br /> AIDS Informallon 469-9820 <br />