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SANJOAQUIN LOCAL HEALTH DISTOCT SERVING <br /> BOARD OF TRUSTEES City of Lodl <br /> James Culbertson, Pres. San Joaquin County ' <br /> Patricia E. Vannuccl, Se4y. 1601 East Hazelton Avenue, P. 0. Box 2009 City of Escalon <br /> Anthonette Van Spronsetl Stockton, Cailfornla95201 City of Manteca <br /> Earl Pimenlel City of Ripon <br /> Fern Bugbee 209/466-6781 City of Stockton <br /> Daniel L. Flores City of Tracy <br /> John D. Mast, M.D. <br /> William J. Wade Jopl Khanna, M.D., M.P.H., District Health Officer San Joaquin County <br /> San Joaquin County <br /> Mary Anna Love <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br /> SITE ASSESSMENT INFORMATION <br /> i <br /> I , the undersigned ow,nler and/or erator of the property and/or facility <br /> located at �q 3 OV�1�+J V,0 S�GK 4 0 tJ 4r • <br /> hereby authorize AI�I E _}f�f4S�Q— � rn_ 2 C'R - cl <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: 7 � ' w Title: Du-�'e <br /> Address 373 / If/ecv��yr !S'c� Phone: f'S'b' 6 zG8 <br /> Date: �z ?� <br /> � e <br /> EH 08 05 <br />