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80ARD Or 1RlISICES <br />JAmaf Culberlaun, Pres. <br />PalrlCla E. Vannuccl, SaC'y. <br />Anihonelle Van Sptonaen <br />Earl Plmenlel <br />Fern Bupbee <br />Daniel L. Florae <br />John 0. Maet, M.O. - <br />William J. Wade <br />Mary Anne Love <br />SAN JOAOUIN LOCAL HEALTH GIST AICT SERVING <br />City of Lodi <br />1601 East Hazelton Avenue, P. 0. Box 2009 San Joaquin County <br />City of Eacalon <br />Stockton, California 95201 City or Manteca <br />209/466-6781 City of Ripon <br />City of Stockton <br />City of Tracy <br />Jopi Khanna, M.D_, M.P.H., Dlatcict Health Officer San Joaquin County <br />ORIGINALJgaquin County <br />AUG {m17Z' 198719Jv� (((I�IIIVVVVJJJ��1' <br />ENVIROMENTAL HEALTH <br />FERMIT/SERVICES• <br />AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br />SITE ASSESSMENT INFORMATION <br />I, the undersigned owner and/or operator of the <br />located at SSS /fes. l�i7i�ri J/ <br />facility <br />G <br />hereby authorize ('Q,�f <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/Opera <br />t <br />io <br />`r <br />`: %('I.,,�� r�hm �. Title Bzz�y1 � <br />Address s31 2 �� t� Phone: <br />CIA— <br />Date: <br />i <br />4039 <br />EH 08 OS UGT 13 <br />