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BOARD OF TRUSTEES <br />At 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 />r • <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 East Hazelton Avenue <br />Stockton, California 95205 <br />JOGI KHANNA, M.D., M.P.X., 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, GEOTECIINICAL DATA AND <br />SITE ASSESSMENT INFORMATION <br />I, the undersigned owner and/or operator of the pro erty and/or facility <br />located at _ 7lrG -' <% � � � G _</il,�� <br />hereby authorize AiUCA� �/`/� v5T 1"S,f,iq� <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. 0 <br />Owner/Operator:a�l" o/'i YJ'y +mow Title/�e�r� <br />Address Phone:9t/4/,- 5T-6 3-,!f <br />Date: r- g � - 9 Y <br />EH 23 041 3/86 <br />Administration Clinical Services Environmental Health <br />468-3400 468-3830 468-3420 <br />Air Pollution Community Services Laboratory <br />468-3470 468-3820 468-3460 <br />AIDS Information 468-3820 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />