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I <br />BOARD OF TRUSTEES <br />James Culbertson, Pres. <br />' Patricia E. Vannuccl, Secy. <br />Anthonette Van Spronse� <br />Earl Plmentel <br />Fern Bugbee <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />I. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 East Hazelton Avenue, P. O. Box 2009 <br />Stockton, California 95201 <br />209/488-6781 <br />Jopl Khanna, M.D., M.P.H., District 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 aty/j, I ��10� _ �SCAvo�l UEL- 2'rA 0�17R� <br />hereby authorize WA'rLR- <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/Op <br />Addhess <br />Date: 9 —,-2— g(f <br />EH 08 05 <br />SERVING <br />City of LodI <br />San Joaquin County <br />City of Eacalon <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 />I <br />5:- <br />9S -3a Q <br />:`9s3ao <br />Title: % l <br />Phone: aoq -838-33a (� <br />!1; <br />p` <br />