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, <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. <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 Escaton <br /> John D,Most M.D. , JOGI KHANNA, M.D.; M.P.H„ DISTRICT HEALTH OFFICERCity of Lodi <br /> Vlrglnla Malhews City of Tracy <br /> Thomas Schubert,D.V.M. ENV I RONMENTAL HEALTH DIVISIONCity of Ripon <br /> r Daphne Shaw ' (2C9) +469-34241 San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> San Joaquin County <br /> S AUTHC3FC I ZAT I ©N T© F ELEASE <br /> 44- ANALYTICAL RESULTS <br /> 44- GEOTECHNICAL DATA . "! <br /> -�- ENVIRONMENTAL/SITE ASSESSMENT INFORMATION JUL 2 089 <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT �( LL ,✓ z - � . <br /> (STRE£I ADDR S ) (CITY) <br /> HEREBY AUTHDRIZE n � - { ` P <br /> (ZADaRATORY or CONS [TANI) <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 YS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> a <br /> TO ME OR MY REPRESENTATIVE, <br /> BUSINESS NAME: doc— <br /> (IF APPLICAOL0 <br /> f i <br /> OWNER/ PERATA <br /> [(PLEASE PRINT) �j(TIT 0 <br /> fS'Is NA URE) <br /> I ADDRESS: 4.70i <br /> (NAILING ADDRESS) <br /> (CITY) (STATE) (ZIP) <br /> i <br /> PHONE: ( ) r/ —<�7 Z-0 <br /> E <br /> DATE: 7 7-4 <br /> EH 23 4141 Revised I/89 <br /> Adminlslrallon t Clinical Services Environmental Health Public Health Nursing <br /> 488-3400 488.3830 488-3420 488-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 488-3470 488-3820 488.3480 <br /> 4$8.3280 <br />