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BOARD OF TRUSTEES <br />James Culbertson, Pres. <br />Pelrlcia E. Vannuccl, Secy. <br />Anthonetle Van Spionsen <br />Earl Pimentel <br />Fern Bupbee <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />S JOAQUIN LOCAL HEALTH DIF IICT <br />1601 East Hazelton Avenue, P. 0. 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 and/or facility <br />located at --7 S J C 1 �h S ci ,��� L <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 />/A <br />Owner/Operator: �t<� Title: <br />Address /11AI /C f l2!2 ( __Phone:// <br />Date: <br />EH 08 05 <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 />