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BOARD OF TRUSTEES SAN JOAQUIN LOCAL. HEALTH DSERVING <br /> At Crow,Pros C9alyco n Joaquin County <br /> Earl Pimenlol,Vice Pros. 1601 f=ast Hazelton Avenue City of Manleca <br /> Tommy Joyce,Sao y. Stockton, Callfornia 95205 TAti 1 pCity of Escelon <br /> James F,Culbertson 1-A AY 0 - 19189 <br /> "8 City of Lodi <br /> u John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews ENVi 0'1tv1E 1-AL H�ALT;-1 City of Rlpon <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH D I V I S I ON'ERrv'.. ;�E=RV.ti S gen Joaquin County <br /> Daphne Shaw (209) 46B--3420 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AIJTHC3FZ I ZA-r I C)N TO FZIELEASIE <br /> - - ANALYTICAL RESULTS <br /> -*�- <br /> GEOTECHNICAL DATA <br /> - ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I$ THE UNDERSIGNED OWNER AND/OR OPERATOR. OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT , fdPOEE, LID. L-6 CA- <br /> (ST <br /> A- <br /> lS1Rr ' AQDRr�fSS e (CITY) <br /> HEREBY AUTHORIZE �=� <br /> (LABORATORY or CONSULTANr) <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 /> ECUSINESS NAME: --5 %l t V 10 � S <br /> (If APPLICABLE) <br /> OWNER/OPERATOR: �'` �( - d t <br /> ASE PRINT) (TITLE) <br /> (s. ruR <br /> ADDRESS: 6b-r' n( C) <br /> (NAILING ADDRESS) <br /> Wov��3 �Lr �4� 6A 5 <br /> (CITY) (STATE) (GIP) <br /> PHONE It f 3 13 l <br /> DATE: <br /> EH 23 041 Revised 1/89 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 460-3420 468.3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 460-3470 468-3820 468-3460 460-3280 <br /> AIDS Inlormation 460-3920 <br />