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OARD OF TRUSTEES <br />gimes Culbertson, Pres. <br />'etricla E. Vannuccl, Sec'y. <br />4nthonette Van Spronsen <br />Earl Pimentel <br />Fern Sugbee <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />SA "AQUIN LOCAL HEALTH DISTRI_ <br />1601 East Hazelton Avenue, P. O. Box 2009 <br />Stockton, California 95201 <br />209/466-6781 <br />Jogl Khanna, M.D., M.P.H., District Health Officer <br />AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br />SITE ASSESSMENT INFORMATION <br />SERVING <br />City of Lodi <br />San Joaquin County <br />City of Escalon <br />City of Manteca <br />City of Ripon <br />City of Stockton <br />City of Tracy <br />San Joaquin County <br />San Joaquin County <br />I, the undersigned owner and/or operator of the property and/or facility <br />located at 9M ga. �AM11,4n'�-�..Gi¢r.��� � VOaQs'�wWot <br />- r — (ZeQ. <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:J�G�� �0. " Title <br />Address 'Z37 K' .i�v lyv' f_ s ✓ _ _Phone <br />say 2 - <br />Date: <br />Date: �— f - Ct,q- <br />EH 08 05 <br />ZbQ . 1a-16ur <br />� � v -56 its -1-7 <br />