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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Patricia E. Vannucci, Secly. San Joaquin County <br /> Anthonette Van Spronse�i 1601 East Hazelton Avenue, P. O. Box 2009 - City of Escalon <br /> Earl Pimentel Stockton, California 95201 City of Manteca <br /> Fern Bugbee 209 466 6761 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade JoOi 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 Werator of the property and/or facility <br /> located at Sq3) 4� �tJ 40- QnGymr-i CPr , 9500E <br /> hereby authorize —(2N�EwATE?, l Nl j Z. . gL& <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/OperatTitle: <br /> Address X393 / I(/ecvTvrr ll'c� Phone: 19 b° 6 7—6' <br /> s ro C 4- <br /> Date: // /o <br /> i s <br /> 1 " <br /> EH 08 05 <br />