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1 (r l <br /> BOARD OF TRUSTEES SA,4 JOAQUIN LOCAL HEALTH DISTRICT <br /> Al Crow,Pres. SERVING <br /> Earl Pimenlel,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.D. JOGI KHANNA, M.D., M.P.H., 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 /> Q 468-34,.-:,o <br /> Harvey Williams,Ph.D. City of Stockton <br /> San Joaquin County <br /> AUTHOR I ZAT I Ohl TO RELEASE <br /> - - ANALYTICAL RESULTS <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 3`160 VJA WEE q0 6R(S DR , 5 I OCTOAJ CA <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE KL EI N FEL�E /91 S S 0 CA rj5S <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 /> DISTRIC_.T AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: O/1k4;0—)� �r/� //' � �. iJ ✓.'f':/J l'i1'G! %� � <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: (1,111, l_ IAI)I'k <br /> (PLEASE PRINT) (TITLE) <br /> (SIGNATURE) <br /> ADDRESS: ���UO !a! �i✓.-% f /,�!? j U<' <br /> (NAILING ADDRESS) <br /> (CITY) (STAIE) (ZIP) <br /> PHONE: (dO 7) %/ <br /> DATE: (�7 <br /> EH 2*C 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 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />