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BOARD OF 1RUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> James Culbertson, Pres. SERVING <br /> Patricia E. Vannuccl, Secy City of Lodi <br /> Anthonelle Van Spronsen 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Earl Plmenlel Stockton, California 95201 City of Escalon <br /> Fern Bupbee City of Manteca <br /> Daniel L. Flores 209/466-6781 City of Ripon <br /> John D. Mast, M.D. City of Stockton <br /> William J. Wade Jopl Khanna, M.D., M.P.H., District Health Officer City of Tracy <br /> Mary Anna Love San Joaquin County <br /> San Joaquin County <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 facility <br /> located at � 5 Cc t- (rc S lerz -/t <br /> hereby authorize 5 I'll , ' t t d <br /> to release any and all analytical results , g`eG`techniiYal 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: l I Qct, Title: <br /> Address ) , s J h Phone: q 6 (�c! <br /> Date: <br /> EH 08 05 UGT 13 <br />