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: 813aRD OF TRUSTEES SAN .IOACaUEN LOCA. HEALTH DISTRICT <br /> SERVING <br /> Loal <br /> JameS Culbef'13an,Pre&. City at County <br /> Patricia E. Vannuccl, Soey. C Sar Joaquin of County <br /> Anthonene Van 5pron3et1 1&01 mast HaZaltan Avenue, P.0. box 2009 City o!Eaca;an <br /> Cit <br /> Eari Pl n-antel Stockton,California 95201 y of Manteca <br /> Rip <br /> Fern 9u oee 209/466-6781 Coy of Stockton 9 City of Stockton <br /> Daniel L. Flores City at Tracy <br /> { Jonn 0. Mast. M.D. <br /> E William J. wade foal Khanna, M.D., M,P.H., District HSs11h atllcor San Joaquin County <br /> San Joaquin County <br /> Mary Anna Lore <br /> V"a <br /> i <br /> is <br /> r=� 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 17000 E. Hiahwav 120, Rinon, CA <br /> R ` hereby authorize California Wager Labs <br /> 3 + to release any and all analytical results, geotechnical data and site <br /> assessment information to the San Joaquin Local Health District as soon <br /> lsr� as it is available and at the.same time it is provided to me or my <br /> representative. <br /> / J <br /> Owner/Operator: '�ta/� :�;�` Title: Z4, <br /> /. ' �.� ?hone: <br /> Address <br /> Cate: /`� ; .� ,7� <br /> Jt• , <br /> EH 08 05 <br />