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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Al Crow,Pres. SERVING <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce.Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mast,M.O. JOGI KHANNA, M.D., M.P.I1., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. <br /> (20.3) 468-3420 City of Stockton <br /> San Joaquin County <br /> AUTHOR I ZAT I ON TO FR E:I_EABE <br /> -�- ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> -*�- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OP, OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT ,�70/ N <br /> (SIR[[[ ADDRESS) (CI1Yl <br /> HEREBY AUTHORIZE <br /> (LABORATORY or CORSU An) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/DR <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 REPRESENTA'rIVE. <br /> 78USINESSNAME: (IF AAffLICABL() <br /> R/OPERATOR: /96'/j <br /> '041ASE PR/Nf) (IIT LE) <br /> (SIGRAIf1RE) <br /> ADDRESS: 7D <br /> (RAILIRG ADDRESS) <br /> (CITY) (SIAIE) tilt) <br /> PHONE: 0175') 4&5-- ,SJ'2 7 <br /> DATE: <br /> EH 23 041 Revised 1//09 <br /> Administration Clinical Servicos Environmental lioalth Public Health Nursing <br /> 468-3400 468-3800 460-3420 <br /> 469-3860 <br /> Air Pollution Cc -roily Services Laboratory WIC <br /> 460-3470 ;8.3820 4G8-3460 <br /> --1 °"` 468-3200 <br />