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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Patricia E. Vannuccl, Secy. 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Anthonette Van Spronsen City of Eacalon <br /> Earl Pimentel Stockton, Callfornla95201 City of Manteca <br /> Fern Butibee 209/466 6781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> Seim D. Mast, M.D. City of Tracy <br /> William J. Wade Jopi Khanna, M.D., M.P.H., District Health Officer San Joaquin County <br /> Mary Anne Love San Joaquin County <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL OXTAANDI�' <br /> SITE ASSESSMENT INFORMATION <br /> I , the undersigned owner and/or operator of the property and/or facility <br /> located at j 5 /1 �i� 3i�1�N �r' k %I SiCCL �G/� Cr� l `� S -ill <br /> hereby authorize <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 /> Pwner/Operator: / lV .l ,., f�� � Title: C <br /> Address 6lqC, Phone: <br /> C6 CT"C iy C a <br /> Date: <br /> EH 08 05 <br />