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GOARD OF Yf,":,, EES <br />James Culbcitcon, Pres. <br />Patricia E. Vennuccl, Secy <br />Anthonette Van Spronsen <br />Earl Plmentel <br />Fern Sugbee <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />SAN J0MUM LOCAL II(:MAJ I DISTRICT <br />ICT <br />1601 East Hazelton Avenue, P. U. Pox 2009 <br />Stockton, California 95201 <br />209/466-6781 <br />Jogi Khanna, M.D., M.P.H., District Hsalth 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 <br />hereby authorize <br />to release any and all analyt' al 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 />represen <br />Owner/Op <br />Address <br />Date: 12-27 -i- S� <br />EH 08 05 <br />Title: <br />Phone: <br />City of Lodl <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 />