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BOARD OF tRUSTEES SAN JOACWIN LOCAL HEALTH DISTRICT SERVING <br /> James Culberlsori', Pre&. t City o1 Lodi <br /> Mary Anna Love,Vice Pres. 1601 East Hazelton Avenue, P.O. Box 2009 "' San Joaquin County <br /> Patricia E.Vannucci, Secy. San Joaquin County <br /> Tommy Joyce Stockton, California 95201 City of Escalon <br /> Earl Pimenlel City of Manteca <br /> Virginia Mathews (209) 466-6781 City of Ripon <br /> Daniel L.Flores City of Stockton <br /> John U.Mast,M.D. Jogi Khanna,M.D.,M.P.H.,District Health Officer City of Tracy <br /> Gene S. Kraham San Joaquin County <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS , GEOTECHNICAL DATA AND <br /> I <br /> SITE ASSESSMENT INFORMATION <br /> A,h-,� /lS <br /> 9 <br /> 1 , ✓the ____�__e+l owner and/or operator of the property and/or facility <br /> located a t /;Z 50_ W /s Gtl �- , _ c___0C . Sri h a- <br /> E 1 <br />+ hereby authorize yyp,ZvQ -C 1y Cj:�'hJ4r4- 7nfl 7-S <br /> 4 <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/Operator : -r"112iGT% 6,1c C'y-.�^Na. Title: <br /> Address /C7rir?0_ c.vic =�Uv�� E3Gc/y - Phone : .z/3 !7L3 9�-76� <br /> k <br /> Date : /z - /b'- 8 7 <br /> I <br /> P KC) <br /> "TtQ� OIL Q00-04 <br /> LLpu,7f� W lTl� eiJQ.i i1� CmN l�t�loll rii�i• <br /> Eli 08 05 UGT 13 <br />