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BOARD OF TRUSTEES <br />.tames Culbertson, Pres. <br />Patricia E. Vannuccl, Secy <br />Anthonette Van Spronsen <br />Earl Plmentel <br />Fern 6upbee <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />SAAAQUIN LOCAL HEALTH DISAT SERVING'. <br />City of Lodi <br />1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br />Stockton, California 95201 City of EscalonClty of Manteca <br />209/466-6781 City of Ripon <br />City of Stockton <br />City of Tracy <br />Jopi Khanna, M.D., M.P.H.. District Health Officer San Joaquin County <br />San Joaquin County <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 0� ?!5 f%.r�/_5 Z7; _ ,27-, `&, <br />hereby authorize-l�/'c�~7 j , '- <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 />Owned'/0 erator: " <br />P � ��.. �ilL ��• Title: <br />Address 12- / 1 Phone:,f�_� <br />Date:' _� , g <br />EH 08 05 UGT 13 <br />