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BiARD OF TRUSTEES <br />Jam" Culbertson, Pr". <br />Mary Anna Love, Via Pres. <br />PoWls E. Vannuccl, Sac'y. <br />Tommy Joyce <br />Earl Pknentel <br />Vkpktls Mathews <br />Daniel L florae <br />Jahn D. Mast, M.O. <br />Gane S. Krahan <br />SAP00AQUIN LOCAL HEALTH DISTA SERVING <br />City of Lodi <br />1601 East Hazelton Avenue, P.O. Box 2008 San Joaquin County <br />San Joaquin County <br />Stockton, Calffornla 85201 City at Escaion <br />City of Manteca <br />(208) 466-6781 City of Ripon <br />City of Stockton <br />Joel Khanna, M.D , M.P.H, Distrid Health Ogew City of Tracy <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 3. Pm. ii k. ae-i/: <br />hereby authorize C14jjc--ycUC <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: �J ' C S Title: 42 cilli1� <br />Address /l%��T/LJ /,/�✓D� �� • Phone: <br />An - <br />Date: -S — 31- <br />Ell <br />1 <br />Eli 08 05 UGT 13 <br />