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Cfttul fvoff► JrnST <br /> :-y � f 1(•2�1�1 <br /> BOARD OF iRusTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> City of Lodl <br /> James Culbertson, Pres. Sen Joaquln County <br /> Patricia E. vannuccl. Secy 1601 East Hazelton Avenue, P. 0. Box 2009 City of Escalon <br /> Anthonette van Spronsen City of Manteca <br /> Earl Plmentel Stockton, California 95201 <br /> City of Ripon <br /> Fern Buobee 209/466--6781 City of Stockton <br /> Daniel L. Flores City of Tracy <br /> John D. Mast, M.O. San Joaquin County <br /> William J. Wade Jopl Khanna, M.D., M.P.H., District Health Officer <br /> San Joaquin County <br /> Mary Anna Love <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br /> SITE ASSESSMENT INFORMATION , <br /> I , the undersigned nWner and/or operator of the property and/or facility <br /> located at XZ� <br /> hereby authorize '� r <br /> to release any and all analytical results, gent nical 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 /> 11/1 Title: <br /> Owner/Operat ' � <br /> p e: - C� <br /> Address <br /> Date: , At, <br /> rz� des re) C4 F0 �" <br />