Laserfiche WebLink
BOARD OF TRUSTEES <br />James Culbertson, Pres. <br />Patricia E. Vannuccl, Sec'y <br />Anthonette Van Spronsen <br />Earl Plmenlel <br />Fern Bupbee <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anne Love <br />%tr <br />n <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 East Hazelton Avenue, P. O. Box 2009 <br />Stockton, Call fornia 95201 <br />209/466-6781 <br />Jopl Khanna, M.D.. M.P.H.. Dletrict Health 011lcer <br />AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br />SITE ASSESSMENT INFORMATION <br />S.f'G*ps4�- - <br />I, the undersigned owner and/or operator of the property and/or facility <br />located at 76�7s- 4///y`�i� 17- <br />th <br />hereby authorize <br />to release any and all analytical results, geottfWhical 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/ <br />Addres <br />Date: <br />a « , <br />-45 `. <br />g� 111'14 We � ��S / �� �� F° .1_0 <br />EH 08 05 UGT 13 <br />SERVING <br />City of Lodi <br />San Joaquln County <br />City of Escalon <br />City of Manteca <br />City of Ripon <br />City of Stockton <br />City of Tracy <br />San Joaquln County <br />San Joaquin County <br />