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BOARD OF TRUSTEES <br />James Culbertson, Pres. <br />Patricia E.-Vannuccl, Secy. <br />Anthonette Van Spronsen <br />Earl Plmeniel <br />Fern Bupbee <br />Daniel L. Flores <br />John D. Me,--reM.D. <br />William 0. Wade <br />Mary Ardis Love <br />`y,e4 JOAQUIN LOCAL HEALTH Dt,�RICT <br />1601 East Hazelton Avenue, P. O. 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 3p$ ,tl C�irCAwJT STltr�f S fzrr�r lv,. C'19 <br />hereby authorize P2CctsID„ * 110 Z), SrreICc ztoC- <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 />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 />Owner/Operator: �e�,,, �r�/y� Title:%%„� <br />Address �� k„t(c Phone: 9y�2 -cp/i/ <br />Date: .3 -y- f 7 <br />