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BOARD Of IRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVINO <br /> Jame, Culbanfon, Pref. <br /> Count <br /> Patricia Vann uccl, SecyCity of Lodi <br /> . San Joaquin Anlhpnetltl0 Van spronean 1601 East Hazelton Avenue, P. O. Box 21x19 q y <br /> Ead Pirnentel Stockton, Callfornia 95201 City of Escalon <br /> Fern Supoee City of Manteca <br /> Daniel L. Flores 209/466-6781 City of Ripon <br /> John D. Masi, M.D. City of Sl ocktonCity of Tracy <br /> William J. Wade Jopi 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 INEOMMIATION <br /> I , the undersigned owner and/or operator of the property and/or 'f ility <br /> located at �¢g (�,�io _�� // <br /> hereby authorize �G �If�rn �a G( ,1fl 1A65 <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 /> Owned/Operator: Title: ,acv--,1oA) eSo,,:.o'.2/.urenJDRA4— <br /> Address P sox /9�7 Phone: '94/— a&.T , <br /> F,2�75.✓O (�� i F 937/ <br /> DdLe: <br /> 'o' �� ��/f C/ OUZO <br /> EH 08 05 UGT 13 ' <br />