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BOARD OF TRUSTEES SAtirJOAQUIN LOCAL HEALTH DISY11ICT SERVING <br /> Jilmea Culbertson, Pres. City of Lod) <br /> Petrlcia E. Vannuccl, Secy. 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Anthonette Van Spronsen City of Escalon <br /> Earl Pimentel Stockton, California 95201 City of Manteca <br /> Fern Bupbee 209/466-6781 City of Ripon <br /> Daniel t . -Pores City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade Jopl 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 Iatntd/or operator of 'the property// and/or facilitt►�,y��// <br /> located at 03 NOf �'PI TYG2 �" - ©C lc OH Q 'k "- <br /> hereby authorize J, H. 14ssoctafPs <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. nr <br /> Owner/Operator: A , Ted CLe.- btE- 3;, tiy� Ti <br /> Address p, 1-5r-x- /5ey" 2 Phone: y,c. <br /> Date: 71(1011�4, <br /> EH 08 05 <br />