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A4 <br />N <br />BOARD OF TRUSTEES ` SAN'JOAQUIN LOCAL HEALTH DISTRICT <br />James Culbertson. Pres.' <br />Palricl■ E. vannuecl. seev, 4, ,. 1601 East Hazelton Avenue, P. O. Box 2009 <br />Anthonette Van Spronsen <br />Earl Plmentel Stockton, Callfornia 95201 <br />Fern Bupbee 209/466-6781 <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade Jopl Khanna, M.D., M.P.H., District Health Officer <br />Mary Anna Love - <br />AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br />SITE ASSESSMENT INFORMATION <br />I, the undersigned owner and or operator of the prop t an /or facility <br />located at %s C�"J <br />hereby authorize <br />to release any and all analyticg results, geotechnical data and site <br />dssessment 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 />Owned/Operator:_ <br />Address <br />Date: (o <br />EH 08 05 UGT 13 <br />Title: <br />Phone: �6�q/ <br />SERVING <br />City of Lodi <br />Sen Joaquln County <br />CRy of Escalon <br />City of Manteca <br />City of -Ripon <br />City of Stockton <br />City of Tracy <br />San Joaquin County <br />Sen Joaquin County <br />