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BOARD OF TRUSTEES <br />James Culbertson, Pres. <br />Patricia E. Vannuccl, Sec'y. <br />Anlhonelle Van Spionsen <br />Earl Plmanlel <br />Fern Supbse <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />S"' JOAQUIN LOCAL HEALTH DIS"CT <br />1601 East Hazellon Avenue, P. O. Box 2009 <br />Stockton, California 95201 <br />209/466-6781 <br />Jopl Khanna, M.D., M.P.H., District Health 011lcer <br />AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br />SITE ASSESSMENT INFORMATION <br />1, the undersigned owner and/or operator of the property and/or facility. <br />located at -7s-7 C l f7riw� , <br />hereby authorize C <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 salne time it is provided to me or my <br />representative. <br />Owner/Operator: -� Title: Z11' <br />Address A'11115/ ✓f3� Phone: / <br />Date: 1-&4 f:: <br />EH 08 05 <br />SERVING <br />City of Lodi <br />San Joaquin County <br />City of Escaion <br />City of Manteca <br />City of Ripon <br />City of Stockton <br />City of Tracy <br />San Joaquin County <br />San Joaquln County <br />