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004HO Of THUSTEES N JOAQUIN LOCAL HEALTH m RIOT SEHVII <br /> James Culbertson,Pres. City of L <br /> Mary Anna Love,Vice Pres. 1601 East Hazelton Avenue, P.O. Box 2009 San Joaquin Cou <br /> Patricia E.Vannuccl,Secy. San Joaquin Cou <br /> Earl Pimanlel <br /> Tommy Joyce Stockton, California 95201 City of Esca <br /> Virginia Malh (20 <br /> ewf City of at Rir <br /> 9) 466-6781 City of Rif <br /> Daniel L. Floret City of Stock' <br /> John D.Mast,M.D. Jogi Khanna,M.D.,M.P.N.,District Health Officer r r•. City of Tit <br /> Gene S.Kraham San Joaquin Cou <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 ? �, � � (�„ter ✓ C ” ��� <br /> hereby authorize _ a <br /> Y �in //1�LJJu <br /> 41 Ao" <br /> to release any and all analytical results, geotechnical data and site �a <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 /> 9 Owner/Operator: ' <br /> Title: 9 <br /> Address p Phone: 3 - S6�S- ✓ <br /> 4 <br /> Date: <br /> Ell 23 041 3/86 <br /> 1:11 <br />