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HOARD OF 1RUSIEES <br />James Cutuenson. P'ea. <br />Palrlcle E. Vennuccl, Secy. <br />Anthonetle Van Swoneen <br />Eeri Plmentel <br />Fern Bupoee <br />Daniel L. Flores <br />John D. Mast. M.D. <br />William J. Wade <br />Mary Anna Lore <br />SA1` _ DAQUIN LOCAL HEALTH DISI._ CT <br />1601 East Hazelton Avenue, P. O. Box 2009 <br />Stockton, California 95201 <br />209/466-6781 <br />Jopl Khanna, M.D., M.P.M., 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 j _)Ar fk,. ZAlL' /'7 n/ Akig7t'.e <br />hereby authorize AIC8r,44 CAt rcN-,7-RWtri,Al <br />to release any and all analytical results, geotechnical data and site <br />dssessment 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 />Ownef/0 <br />Address <br />Date: <br />erator: �r <br />p Title: <br />( Phone: <br />Cl <br />I H 08 05 . 1)G1 13 <br />[O.r <br />Uri,; <br />MAS <br />s� <br />ENVIR MIT/tjERVIC SLtH <br />PER <br />r, <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 />