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aJAfD OF TRUSTEES SAN J� ' QUIN LOCAL HEALTH DISTRII SERVING <br /> James Culbe-von. Pres. v - - ,,,,. <br /> PalrOa E. Vannuccl, Soc*y. San Joaq Iltn Couny of ty <br /> Anihonetle Van Spronsen 1601 East Hazelton Avenue, P. O. Box 2009 <br /> City of Escalon <br /> Earl Plm enlel Stockton, Calltornia 95201 Cily of Mantoca <br /> Fain Supoea 2U9/466-6781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John D: Most, M.O. City of Tracy <br /> William J. Wade Jopi Khanna, M.D., M.P.H., District Health Officer Sen Joaquin County y <br /> Mary Anne Love San Joaquin County <br /> 00416 <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br /> SITE ASSESSMENT INFORMATION <br /> I , the undersigned owner and/or operator of the property and/or /fac'ility <br /> located at oZOQ/ Cf�Are�E2 _IG�J•�1 S7L�=�1�✓, C4 <br /> hereby authorize �,¢G��D/?�tA 7 )A7—E2- ?-ge <br /> to release any and all analytical results, geotechnical data and site <br /> dssessment 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 /> Owned/Operator: Title; <br /> Address 2 t /V V t Phone 7 �C7`2 3 20Q" <br /> — Lo ( � lL li—= <br /> Date: r_ 1" 5 _ -7 <br /> V I <br /> A #111 <br /> OK` <br /> a <br /> EH 08 05 UGT 13 <br />