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BOARD OF TRUSTEES SAS-rJOAQUIN LOCAL HEALTH DIS.AICT SERVING <br /> James Culbertson, Pres. City of Lodl <br /> Fatrlcla E. vannuccl, Sec'y. 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Anthonette Van Spronsen City of Escalon <br /> Earl Plmentel Stockton, California 95201 City of Manteca <br /> Fern Bugbee 209/466-6781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade Jogi 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 , the undersigned owner and/or gerator of the proe ty and/or fa ility <br /> located at <br /> hereby authorize <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: ss Title: /I( <br /> AddressPhone: /r?119—'91pZ-d7/ 0 <br /> x <br /> OF <br /> Date: Q�— J�• /Q�l`— <br /> EH 08 05 <br />