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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> j James Culbertson, Pres. City of Lodi <br /> San Joaquin County <br /> Anthola tt Van Spro Segfr• igpi Est Hazelton Avenue, P. O. BOX 2009 City of Escalon <br /> Anthonetts Ven Spron <br /> Earl Pimentel Stockton, Callfornla95201 city of Manteca <br /> Fern Suybee209 488-878t City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J.Wade Jopl Khanna, M.D., M.P.H., District Health Officer San Joaquin County <br /> Mary Anna Love San Joaquin County <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br /> SITE ASSESSMENT INFORMATION <br /> i <br /> t <br /> I , the undersigned owner and/or operator of the property and/or facility <br /> located at /P30 �jo • CFA/TkAL Avg, �LOQ/ 04, <br /> hereby authorize (mux LVVEk ,LABS _ /'t'IO0ESTo , OA <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 /> I representative. <br /> Owner/Operator: Title: <br /> Address IQ30 5 _ CW*wt- �F. Phone: — D <br /> � glµ l (��I � <br /> Date: 15 — <br /> i <br /> EH 08 05 <br />