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BOARUOF TRUSTEES <br />./amee'Celben,3on, Pres. <br />Palricle E. Vannuccl, SeC'y <br />Anthonette Van Spronson <br />Earl Pimenlel <br />Fern Suobee <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />SArWAQUIN LOCAL HEALTH MSTffT <br />1601 East Hazelton Avenue, P. O. Dox 2009 <br />Stockton, Callfornia 95201 <br />209/466-6781 <br />Jooi Khanna, M.D., M.P.H., Dletrict 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 /S.a/ o5�oc�1>—d J ST <br />hereby authorize C/fi�o�r/ic tvv1x2�,v��.�7g� SgRrrs C_a2G <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 />Owner/ Operator:c�d ljs�c/t Title: /i7/:rivToFo�t, <br />.r— <br />Address ��/, ��L 5y— Phone: <br />Date: <br />EH 08 05 UGT 13 <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 />