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BOARD OF TRUSTEES St . '. JOAQUIN LOCAL HEALTH DIS"ICT SERVING <br /> James Culbertson, Pres. . City of Lodi <br /> Patricia E. Vannuccl, Sec'y. 1601 East Hazelton Avenue, P. 0. Box 2009 San Joaquin County <br /> Anthonetle Van Spronsen City of Escalon <br /> Earl Plmental Stockton, California 95201 City of Manteca <br /> Fern Bupbee 209/466-6781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade JoVI 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 operator of the property and/or facility <br /> located at a900 S C A, � -Le'-SQA SX- <br /> hereby authorize CA,--, »'�t--, 1� A. <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 salve time it is provided to me or my <br /> representative. /y <br /> Owner/Operator: Title: i <br /> Address Phone: C 3' <br /> Date: (y <br /> EH 08 05 <br />