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A <br />BOARD OF TRUSTEES <br />At Crow, Pres. <br />Earl Pimenlel, Vice Pres, <br />Tommy Joyce, Secy. <br />James F. Culbertson <br />John D. Mast, M.D. JOGI, KHANNA, M.D.; M.P.H., DISTRICT HEALTH OFFICER <br />Virginia Mathews <br />Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION <br />Daphne Shaw ( 209) 46$-342o <br />Harvey Williams, Ph.D. <br />^U_r" lFR!I -r C3 FZr=:1 E:^E3a <br />' 0 <br />SAIJOAQUIN LOCAL HEALTH DISTRICT <br />1601 East Hazelton Avenue <br />Stockton, California 95205 <br />--%*- ANALYTICAL RESULTS <br />I <br />-- GEOTECHNICAL• DATA <br />-- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />SERVING <br />San Joaquin County <br />City of Manteca <br />City of Escslon <br />City of Lodi <br />City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />I, THE -UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT V <br />:(STREET ADDRESS) (CITY) <br />HEREBY AUTHORIZE_ C_^ hi 0 a I E, <br />(LABORRTORY or CONSULTAAT) <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 AVAILADLE AND AT THE SAME -TIME IT IS PROVIDED <br />TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME <br />�((IF APPLICABLE) <br />OWNER/OPERATOR:�� <br />(PL A.SE PRINT) (TITLE) <br />{ <br />(S10ATURE) . <br />ADDRESS: <br />0AILIHO ADDRESS) <br />� GGA'-� C� • �`� Z`� <br />(CITY) ,�, (STATE) (IIP) <br />PHONE: (�5) LO--7/(lo t41f <br />DATE: <br />EH 23 041 Revised 1 /S'D <br />Administration Environmental Health Public Hoalth Nursing <br />468-3420 468-3860 <br />Laboratory WIC <br />168-3460 4G8-32.80 <br />Clinical Seryicos <br />468-3400 <br />468-3830 <br />Air Pollution <br />Community Services <br />468-3470 <br />468-3820 <br />