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SUARD Of IkuS It(S <br />timer Culberlson, {,as. <br />PaluU: E. Vannuccl. Secy. <br />Anthonetts Van Spronaen <br />Earl Plmentel <br />Fern nugbee <br />Daniel L. Flores <br />John D. Mast. M.D. <br />William J. Wade <br />Mary Anna Lore <br />SAN AQUIN LOCAL HLALI H DIST I T <br />1601 East Hazellon Avenue, P. O. Box 2009 <br />Stockton, California 95201 <br />209/466-6781 <br />Jogl Khanna, M.D., M.P.N., District Heaflh 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 and/or facility <br />located at I ,- 7) C <br />h 0 A — v, \ („ <br />hereby authorize II8�J1E�egf,21 <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 />Owned/Operator: <br />Address <br />Date: <br />EH 08 05 UGT 13 <br />Title: <br />Phone: ZZ <br />SLRVINO <br />City of Lodl <br />San Joaquin County <br />City of Escalon <br />City of Maniacs <br />City of Ripon <br />City of Stockton <br />City of Tracy <br />San Joaquin County <br />San Joaquin County <br />