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J <br /> OF IflUSIEE5 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Culborison, Pres. <br /> cle E. Vannuccl, Secy CltyoTLodl <br /> 1601 East Hazelton Avenue, P. O. Box 2009 San Joaqufn Count <br /> honette Van Sprnnson y <br /> rl Plmonlol l City of Escalon <br /> Stockton, California 95201 : city of Mantoca <br /> am Buobee <br /> Daniel L. Flores 209/466-6781 City of Rlpon <br /> City of Stockton <br /> John D. Masi, M.D. ' y Tracy <br /> William J. Wade Jool Khanna., M.D., M.P.H., District Health Offlcer San Joaquin oCounty <br /> Mary Anna Love <br /> San Joaquin County <br /> i <br />� E " <br /> r <br /> r <br /> Ii <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND t <br /> SITE ASSESSMENT INFORMATION t <br /> I , the undersigned owner and/or operator of the <br /> I property and/or facility <br /> located at <br /> hereby authori ze <br /> f <br /> to release any and all analytical results , geotechnical data and site M <br /> assessment information to the San Joaquin Local Health! District as soon i <br /> as it is available and at the same time it is provided'to me or my <br /> i , <br /> representative. <br /> o <br /> Owner/Operator: i ,—�.� , 1,. i.� _T. - Title: <br /> `I <br /> I Address y�25 Phone: <br /> Date: <br /> I <br /> 3 <br /> 'I <br /> I <br /> i <br /> 6 <br /> i <br /> i <br /> I ; <br /> Cl1 nn nr E Er`T -i iI <br />