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'sT.a Culbonaor,, Pt.n• <br />Petticta E. vant�uod, fiK•y. <br />An61~ts van ttpton"n <br />Ewf rtTantal <br />Fair eugb" <br />panbl L Floras <br />John D. Mast. M.O. <br />wunant J. W"* <br />Marls Anna Low <br />SA AQUIN LOCAL HEALTH DISTOIT <br />1601 East Hatelton Avenue, P. 0. Box 2409 <br />Stockton. Catlkwnfa 95201 <br />209/466-6781 <br />Jop1 Khanna„ M.D.. M.P.N., District Nwtth (X(lcar <br />AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL. DATA AND <br />SITE ASSESSMENT INFORMATION <br />SERvwo <br />Gtr of Lodi <br />S®n Joaquin County <br />Gtr of Escatoo <br />City of MantKa <br />city of Ripon <br />City of Stockton <br />City of Tracy <br />San Joaquin County <br />Sat Joaquin County <br />I, the undersigned owner and/or operator of the property and/or facility <br />located at <br />hereby authorize <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 />�- o P4 -Ckt.NNr iAf <br />Owned/Opera.tor: / <br />Title: <br />Address $ d e l 41- Q za�F <br />�'7� ��., - iV`{C-tCCI�. ��VC� Phone:(Z0 )33 q-3gtl <br />-' <br />x �z � <br />Date: <br />Ir <br />\.EH 08 OS UGT 13 <br />e <br />