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BOARD OF TRUSTEES <br />James Culbertson, Pres. <br />Patricia E. Vannuccl, Sec'y. <br />Anthonette Van Spronsen <br />Earl Pimentel <br />Fern Bugbee <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />0 �& <br />SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br />City of Lodi <br />1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br />City of Escalon <br />Stockton, California 95201 City of Manteca <br />209/466-6781 City Ripon <br />City of Stockton <br />City of Tracy <br />Jogi Khanna, M.D., M.P.H., District Health Officer San Joaquin County <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 <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: Title: <br />Address t C - Fa- Phone: <br />Date: % �l <br />