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BOARD OI TRUSTLLS '{ <br /> SAN JOAQUIN LOCAL HEALTH DISTAICT <br /> James Culhsrt,on. Prni. i SERVING A i <br /> Peblcla E.Vannuc U, Secy i` I <br /> City of Lodi <br /> .Anihonutle Van SPrun,un 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County ' <br /> Earl Plmanlgl Stockton, Calllornia 9.5?01 1 City ofEacalon <br /> Fern f7up Uvu City of Manteca .{p <br /> Daniel L. Flores 209/466-6781 I City of Ripon .i I <br /> John D. Mast, M.D. City of Stockton , <br /> William J. Wade Jopl Khanna, M.D., M.P.H., District Flealtn Officer city of Tracy <br /> ..Mary Anna Love I San Joaquin County <br /> San Joaquin County <br /> I <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br /> SITE ASSESSMENT INFORMATION <br /> I <br /> ••7i E <br /> I H <br /> I , the undersigned owner and/or operator of the property and/or facility <br /> located at j .7 �� �7 Ci;� /?.0 Gtif LCA✓7j <br /> hereby authorize L�/�'(_�!i� ��'�j�L7��/C/..;!. <br /> to release any and all analytical results, geotechnicalidata 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 /> y� <br /> Owner/Operator: Si eJtir�� Title! GCIL,;EK' <br /> Address />lG�,'7-d Gilr. Phone. '3l �./,z /S <br /> Date: ---- ---- l <br /> �6%X <R-6.20 � <br /> I <br /> FX <br /> 'o= o <br /> I <br /> Eli 08 05 <br />