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BOARD OF TRUSTEES <br />James Culbertson, Pre3. <br />Pairicla E. Vannuccl. Sec'y <br />Anthonelte Van Spron3en <br />Earl Plmentel <br />Fern Bugoee <br />Daniel L. Flore3 <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />SAI OAQUIN LOCAL HEALTH DISI_ .CT <br />1601 East Hazelton Avenue, P. 0. Box 2009 <br />Stockton, Callfornia 95201 <br />209/466-6781 <br />Jopl Khanna, M.D., M.P.N., Dlatrict Health Officer <br />AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br />SITE ASSESSMENT INFORMATION <br />SERVING <br />City of Lodi <br />San Joaquln County <br />City of E3calon <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, the undersigned owner and/or operator of the property and/or facility <br />located a t -j1,7-5 �t/, <br />hereby authorize �tgil,���j �i]/tiz2e v � L-__ 1� j c Com, <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 />ry",j= l44/ <br />Owner/Operator: Title: <br />Addre.s o2.c'/ , ,'lam � 5 T Phone: <br />Date: % <br />EH 08 05 UGT 13 <br />