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BOARD OF TRUSTEES SAN #QUIN LOCAL HEALTH DISTR4 SERVING <br /> James Culbartson, Pros. City of Lodi <br /> Pa Ir Icit E. Vannuccl, Secyuln Count. San Joa <br /> Anlhonella Van Spronsan 1601 East Hazelton Avenue, P. O. Box 2009' q y <br /> , Pimontel City of Ea <br /> For Maniacs Stockton, California 95201 City of Mannteca <br /> Fern aupooe 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., Diatrlct Health Officer San Joaquin County y <br /> Mary Anne 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 Li�,�nn� Cr �a � ite� . 2 . S�o�� — �f <br /> hereby authorize l" cC F}�Ll�� <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 /> Owned/Operator s _ Ti tle <br /> Address --;57-5s Phone: _ �i <br /> Q$ � 9�3- 5755 <br /> . o <br /> '.�a <br /> a <br /> EH 08 05 UGT 13 <br />