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90ARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Patricia E. Vannuccf, Secy. 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquln County <br /> Anthonette Van Spronsen City of Escalon <br /> Earl Pimentel Stockton, California 95201 city of Manteca <br /> Fern Bupbee 209/466-6781 City of Ripon <br /> Dante! L. Flores City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade Jopl Khanna, M.D., M.P.M., 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 Z/:2 <br /> hereby authorize , ,���� <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 /> Ownef/Operator: Title: <br /> Address 7/U Phone: <br /> Date: <br /> JAN 1 — <br /> ENVIRC,V&P+TAL HEALTH <br /> F ERM IT/SERVICES <br /> EH 08 05 UGT 13 3 a r <br />