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SERVING <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT City of Lodi <br /> James Culbertson, Pres- San Joaquin County <br /> Patricia E. Vannucci, Secy. 1601 East Hazelton Avenue, P. 0. Box 2009 City of Escalon <br /> Anthonette Van Spronsen Stockton, California 95201 City of Manteca <br /> Earl Pimentel City of Ripon <br /> Fern Bugbee 209/466-67$1 City of Stockton <br /> Daniel L. Flores City of Tracy <br /> John D. Mast, M.D. San Joaquin County <br /> William J. Wade Jogi Khanna, M.D., M.P.K.. District Health Officer San Joaquin County <br /> Mary Anna Love <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 11J l�rnrf� ` <br /> hereby authorize �3 - ----- - <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: <br /> Title: U5, L6 AP <br /> Address Phone: a3g r rS <br /> ti <br /> Date: L /4 & _.,. <br /> w ri 4 <br /> EH 08 05 <br />