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BOARD OR TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> odi <br /> James Culbertson, Pres. City of <br /> Patricia E. Vannucci, Sec'y. 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Anthonette Van Spronsen City of Eacalon <br /> Earl Pimentel Stockton, California95201 City of Manteca <br /> Fern Bugbee 209/466-6761 City of Ripon <br /> City of Stockton <br /> Daniel L. Flores <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade Jogi 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 /Q. aer eG L.J'_ —/ yLTE/A4 <br /> hereby authorize '7/f 4 E'ilG✓@/" f- /9556 0 <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: *Q/ <br /> Address Phone <br /> Date: �� ���iJ► <br /> EH 08 05 <br />