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HOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH D1STR CT <br /> Al Crow,Pre& 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 O.Mast M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER Cit'of Lodi <br /> Vlrginla Mathews City of Tracy <br /> Thomas Schubert,D.V.M. ENVIRONMENTAL HEALTH D I V I S I ON City of Ripon <br /> Daphne Shaw <2t13> X58-342Q San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> AUTHC3FR I ZAT ION TO !lamELEAE3E San Joaquin County <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 <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE <br /> (LABORATORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAUUIN 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 /> ESUS I NESS NAME• A-D�:T-" <br /> (IF APPLICABLE) -- <br /> OWNER/OPERATOR: X �p <br /> (PLEAS PRINT) (TITLE) <br /> X - <br /> (516NAlURE1 <br /> ADDRESS: .. <br /> (NAILM6 ADDRESS) <br /> (CITY) (STATE) (IIP) <br /> PHONE: <br /> DATE: X e <br /> EH 23 041 Revised 1/89 <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 468-3820 468-3450 468-3280 <br /> AIDS fntormetlon 46p-.wo <br />