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BOARD OF TRUSTEES S• JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> San Joaquin County <br /> At Crow,Pres. <br /> Earl Pimentel,vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.M., DISTRICT HEALTH OFFICER City of Tracy <br /> City of Ripon <br /> Virginia Mathews <br /> San Joaquin County <br /> Thomas Schubert,D.V.M. <br /> City of Stockton <br /> Daphne Shaw <br /> Harvey Williams,Ph.D. 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 33 /baa n/c& Sz GI � <br /> hereby authorize J /-/ 11' le%d <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/Operator: 5i&'W i CY y✓ /'/ -R r z_ Title: 10�1I_ <br /> Address ?15 s lr / t✓ G� x� ✓ CiPhone: ;3yi 6293dj- <br /> A.1'G�� <br /> Date: //I /S <br /> EH 23 041 3/86 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3630 468-3420 468.3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468.3280 <br /> PIDR infnrmalion nFa In" <br />