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BOARD Of:. TRUSTEES <br />James CulDen gory. Prea. _ <br />Patricia E. Vannuccl, Ssc'y <br />Anlhonstle Van Spronsen <br />Earl Plmanlel <br />Fern Bupbee <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />SAN J� .AQUIN LOCAL HEALTH DISTRIr" <br />1601 East Hazelton Avenue; P. O. Box 2009 <br />Stockton, California 95201 <br />209/466-6781 <br />Jopl Khanna, M.D., M.P.H., District Health Officer <br />AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br />SITE ASSESSMENT INFORMATION <br />I, the undersigned owner and/or operator of the property 4nd/or .facilit <br />located at <br />hereby authorize <br />to release any and all a alytical 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 />-R - �,!%X, c'rS <br />Owned/Operator:( �Q,,7 Title R <br />Addresses 73 1, Ij9 Phone: k S3 y',f <br />Date:X <br />EH 08 05 UGT 13 <br />SERVING <br />City of Lodi <br />San Joaquin County <br />City of Escalon <br />City of Manieca <br />City of Ripon <br />City of Stockton <br />City of Tracy <br />San Joaquin County <br />San Joaquin County <br />