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BOARD OF TRUSTEES SAOAQUIN LOCAL HEALTH DISOICT SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Patricia E. Vannuccl, sec y. 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Anthonette Van Spronsen City of Escalon <br /> ` Earl Plmentel Stockton, California 95201 City of Manteca <br /> Fern Bugbee 209/466-6781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade Jopl 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 three property <br /> 1 and/or facility <br /> located at gy74' Al-U {7llib/u)(4- V 57 ff/b <br /> hereby authorize , i A&sDc1 T6S <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/Opera`fo 1, �� --- Title: �xJ 6r C?Lw l - <br /> Address 2/6/ C ! �Phone:C2o ' !!;,f 3 <br /> Date: — Z — c <br /> EH 08 05 <br />