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CT SERVING <br /> JOAQUIN LOCAL HEALTH DI city of Lodi <br /> BOARD OF TRUSTEES _,� San Joaquin County <br /> James Culbertson, Pres. p, Box 2009 City of Escalon <br /> Patricia E. Vannuccl, Secy. 1601 East Hazelton Avenue, P. City of Manteca <br /> Anthonette Van Spronsen Stockton, California 95201 City of Ripon <br /> City of Stockton <br /> Earl Plmentel 209/466-6781 City of Tracy <br /> Fern Bugbee <br /> Daniel L. FloresSan Joaquin County <br /> John D. Mast, M.D. Jogi Khanna, M.D., M.P.H., District Health officer San Joaquin County <br /> William J. Wade <br /> Mary Anna Love <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br /> SITE ASSESSMENT INFORMATION <br /> I, the undersigned ownQrl 04ouuratortof the roperty and/or facility <br /> located at SCOPPc��kkRoPOI IS uh�►� f—L.OTA _t> <br /> hereby authorize 1y3o /ar o_w7 e a7eoatr �P� */aSc- <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 /> 0 <br /> (Owner/Operator: ✓S5eC Title: <br /> V(%ddress ra.a S�eE;F Phone:, <br /> ,<Date: <br /> EH 08 05 <br />