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• .• <br />.BOARD OF TRUSTEES <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />SERVING <br />AI Crow, Pres. <br />San Joaquin County <br />Earl Pimentel, Vice Pres, <br />1601 East Hazelton Avenue <br />City of Manteca <br />Tommy Joyce, Secy. <br />Stockton, California 95205 <br />City of Escalon <br />James F. Culbertson <br />City of Lodi <br />John D. Most, M.D. <br />JOGI, KHANNA, M.D.; M.P.H., DISTRICT HEALTH OFFICER <br />City of Tracy <br />Virginia Mathews <br />Cl 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 />^U-r"QF;Z'I ZA-r I OM 'TM FRE:L—EASE <br />-- ANALYTICAL RESULTS <br />-- GEOTECHNICAL DATA <br />-- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OP, FACILITY <br />LOCATED AT _> 4:2 <br />(STREET ADDRESS (CITY) <br />HEREBY AUTHORIZ <br />(LABORATORY or CONSULTANT) <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. IV,I C, au all <br />BUSINESS NAME: C <br />OWNER/OPERATOR: <br />ADDRESS <br />(IF APPLICABLE) <br />J 0 N 15 1990 <br />ENVIRONMENTAL HEAI.T' <br />1S16NATURE) <br />!MAILING ADDRESS) <br />-�Q-A+ <br />(CITY) (STATE) (ZIP) �— <br />PHONE: (415) 67,0-1414 <br />DATE: (n�lzJ <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 Hoalth Nursing <br />468-3860 <br />WIC <br />468-3280 <br />