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BOARD TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT1 <br /> James Culbertson. Prea. SERVING <br /> Patricia E. Vannuccl, Secy Clly of Lodi <br /> Anthonstte Van Spronsen 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Earl Pimentel Stockton, California 95201 City of Eacelon <br /> Fern Bupbee Clly of Manteca <br /> Daniel L. Flores 209/466-6781 clay 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 Anne 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 f/O <br /> hereby authorize <br /> to release any and all analytical results, g technical data and site <br /> assessment information to the San Joaquin Local Health District as soon <br /> as it is available and at the timei ` is provided to me or my <br /> representative. G/�� , / <br /> Owner/Operator: � ,;� Title: �� <br /> Address 9/o '5&? _ Phone: <br /> Date: <br /> EH 08 05 UGT 13 <br />