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BOARD OF TRUSTEES JOAQUIN LOCAL HEALTH DIICT SERVING <br /> James Culbertson, Pres. <br /> Patricia E. Vannuccl, Secy. City of Lodi <br /> San Joaquin County <br /> Anthonette van Spronsen 1601 East Hazelton Avenue, P. 6i BOX 2009 <br /> Earl Pimentel Stockton, California 95261 city of Escalon <br /> i City of Manteca <br /> Fern Bugbee <br /> City of Ripon <br /> Daniel L. Flores 209/466-6781 <br /> City of Stockton <br /> John D. Mast. M.D. j <br /> City of Tracy <br /> William J. Wade Jogl Khanna. M.D., M.P.H., District Health Officer <br /> San Joaquin County <br /> Mary Anna Love San Joaquin County <br />; <br /> i <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br /> I <br /> SITE ASSESSMENT INFORMATION <br /> s <br /> j <br /> I, the undersigned owner and/or operator of the prooertyi and/or facility <br /> i <br /> located at �?Q s ���,�� Z/'A/C�eA-, 's-7- <br /> hereby <br /> .-Thereby authorize l� is <br /> d d e <br /> e n and all- analytical tical results geotechnical ata an site <br /> to release a a <br /> y y � <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 /> ii <br /> F representative. <br /> Owner/Operator Title: Q /Y� <br /> it <br /> Address �D ' �OU�y %(�l�Z�y Phone: ����. �2 <br /> Az <br /> I Date: Aq4 i <br /> 1 <br /> { <br /> 1 <br /> f <br /> I <br /> EH 08 05 ; <br />