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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Patricla E. Vannuccl, Sec'y. 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Anthonette Van Spronsen City of Escalon <br /> Earl Pimentel 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 Jog! 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 �'� �SOi(; GC-�A `/ <br /> hereby authorize L�'aZ/;c: LC;470f^ Z-14 b5 <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 /> 2 <br /> Owner/Operator: ,c�i;�M ,���o-�� Title: <br /> Address Phone: <br /> Date: /ie, <br /> 7 .1 <br /> 2�- /-�s <br /> EH 08 05 <br />