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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> James Culbertson. Pres. SERVING <br /> Patricia E. Vannuccl. Secy, Cllyof Lodi <br /> Anlhonelte Van Spronsen 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Earl Plmenlel Stockton, California 95201 city of Escalon <br /> Fern BupDen City of Manteca <br /> Daniel L. Flores 209/466-6781 City of Ripon <br /> John 0. 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 /> Fah 4Gs �Q/L, lg <br /> F,p�i�jFNrq 7��6 <br /> l <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 _Coco <br /> i) , w-N p <br /> hereby authorize CArt �l�� Its le�r�tcQ A � SNS <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. e, <br /> Owner/Operator: �j9.� <br /> _cam-----� Title: <br /> Address (� �� 4 `�_ �� UC) <br /> C 7 Phone: <br /> \�r2 S CA R C?a 1 <br /> Date: <br /> EH 08 05 <br />