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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Patricia E. Vannucci, 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 Bugbee 209/466-6781City 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 operator of the property and/or facility <br /> located at Z/3 Z,/ 3 L. 14r-e•7o . 7' -S7, S-7bcKftnn JS�O� <br /> hereby authorize y % ['Ok P. <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: '2_ 4Title: <br /> Address 3 Phone: �05 7y�/� 3 y <br /> c1`}- 9 S-ac) J' _ <br /> Date: <br /> EH 08 05 <br />