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e0AR0 OF TRUSTEES <br />James Culbertson, Pres. <br />Patricia E. Vannuccl. Secy <br />Anlhonetle Van Spronsen <br />Earl Plmentel <br />Fern Bupbee <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <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 />1, the undersigned owner and/or operator of the property and/or facility <br />located at 7 75 tv / —0, /th <br />hereby authorize <br />to release any and all analytical results, geot nical data and site <br />assessment information to the San Joaquin Local Health District as soon <br />as it is available and at the salve time it is provided to me or my <br />representative. <br />Owner/Operat <br />Address .- <br />Date: /�7 - t -f -- <br />SERVING <br />City of Lodi <br />San Joaquin County <br />City of Escalon <br />City of Manleca <br />City o1 Ripon <br />City of Stockton <br />City of Tracy <br />San Joaquin County <br />San Joaquin County <br />_Title: <br />PJt one: C� <br />n � FO o <br />