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BOARD O( IRUSTEES <br />James CWuenson. Pre,. <br />Patricia E. Vannuccl. Secy, <br />Anlhonelle Van Sp(Onsen <br />Earl Plmenlal <br />Fern Oupoee <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />SERVING <br />1601 East Hazellon Avenue, P. O. Box 2009 <br />City of Lod$ <br />San Joaquin County <br />Stockton. California 95201 <br />City of Escalon <br />city of Manteca <br />209/466-6781 <br />City of Ripon <br />City of Stockton <br />Jopl Khanna, M.O., M.P.H., District Health Officer <br />City of Tracy <br />San Joaquin County <br />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 / -2-f �- .t/` if _ 49— '_!' /)v J? I ,n <br />hereby authorizeLEj,1/[rf�����5®cJy�7�eyrj,;yPy/_ <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:Title: ft,�i .2c <br />AddressPhone:�A—--,5- <br />Date: <br />ENVIkv'.vtw i AL t �AL7H <br />FERI�j 1 /SERVICES <br />EH 08 05 UGT 13 <br />