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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. City of Lodl <br /> Patricia E. Vannuccl, Secy. 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> calon <br /> Anthonette Van Spronsed CEa <br /> Earl Pimentel Stockton, Callforn1a95201 City <br /> of Manteca <br /> Fern Bugbee 209/466-6781 City of Ripon <br /> Daniel L. Flores City Stockton <br /> John D. Mast, M.D. City of Tracy <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 2aL4_ Rt �1F , - MA1,)7-6CA <br /> hereby authorize 0 AL I F IA24,�T—&Cf 1-0'PS <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: cc� Zu et / Title: C2W o0 6(�- <br /> Address L41 - Phone: a0 9 - go-2 7 S/ <br /> a'YIAlt)-T-E ca (b L.I F . <br /> Date: <br /> !1; <br /> S <br /> PAYMENT <br /> RECEIVED <br /> SEP 2 lydd <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SER VICES <br /> EH 08 05 / <br />