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BOARD OF TRUSTEES <br />Al Crow, Pres. <br />Earl Pimentel, Vice Pres. <br />Tommy Joyce, Secy. <br />James F. Culbertson <br />John D. Mast, M.D. <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />SAN JOAOUIN LOCAL HEALTH DISTRICT <br />1601 East Hazelton Avenue <br />Stockton, California 95205 <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />SERVING <br />San Joaquin County <br />City of Manteca <br />City of Escalon <br />City of Lodi <br />City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br />SITE ASSESSMENT INFORMATION <br />I, the undersigned owner and/or operator of the property and/or facility <br />located at <br />hereby authorize ADnl i�� i L--'Ten� <br />to release any and all analytical results, geotechnical data and site <br />assessment information to the San Joaquin Local Health District as soon <br />as it is available and at the same time it is provided to me or my <br />representative. <br />Owner/Op <br />Address <br />Date: �i-I- <br />EH 23 041 3/86 <br />Administration <br />Clinical Services <br />468-3400 <br />468-3830 <br />Air Pollution <br />Community Services <br />468-3470 <br />468-3820 <br />Environmental Health <br />468-3420 <br />Laboratory <br />468-3460 <br />AIDS Information 468-3820 <br />Title: t46 -t :�`.V-K —'. <br />Phone: 1/6 � <br />-s--(S <br />Public Health Nursing <br />468-3860 <br />Wit, <br />468-3280 <br />