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BOARD OF TRUSTEES SA ROAQUIN LOCAL HEALTH DISAT SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Patricia E. Vannucci, Sec'y. 1601 East Hazelton Avenue, P. O. BOX 2009 San Joaquin County <br /> Anthonetle Van Spronsen Clty of Escalon <br /> Earl Pimentel Stockton, California 95201 City of Manteca <br /> CityFern Bugbee 209/466-6781 City of <br /> Ripon <br /> City <br /> Daniel L. Flores Stt ockton <br /> John D. Mast, M.D. CityolTracy <br /> William J. Wade Jogl 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 AZ m /S 'y Loce-fwA' �zT L m> .x <br /> hereby authorize 1,/p ss /Iss')C i � <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: � � /icy Title: <br /> Address Phone: aa�� ���' � <br /> Date: <br /> EH 08 05 <br />