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BOARD OF TRUSTEES SAN ,AQUIN LOCAL HEALTH DISTR SERVING' <br /> James Culbertson, Pres. Clly of Lodl <br /> Patricia E. Vannuccl, Secy. San Joa uln <br /> Anthonette Van Spronsen 1601 East Hazelton Avenue, f. 0. BOX 2009 q County <br /> Escalon <br /> Earl Pimenlel Stockton, Callfornia 95201 city <br /> Fern Bupbee City off Manteca <br /> Daniel L. Flores 209/466-6781 City of Ripon <br /> City of Stockton <br /> John D. Mast, M.O. City of Tracy <br /> William J. Wade Jopl 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 / 11I2-ce-1OD lez), 7l/l <br /> hereby authorize <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: Title: <br /> Address <br /> /� _ Phone• ��� ��f—��� <br /> Date: •- <br /> (4�e w7 /— fi�c— <br /> EH 08 05 UGT 13 <br />