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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Patricia E. Vannuccl, Sac'y. San Joaquin County <br /> Anthonette Van Spronsen 1601 East Hazelton Avenue, P. O. Box 2009 City of Escalon <br /> Earl Plmentel Stockton, Callfomia95201 city of Manteca <br /> Fern Bupbes 209/466$781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade Jopl 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 _;2 rj /C—E <br /> hereby authorize <br /> to release any and all analytical resu s, 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 /> representa�e.ly.1 zl� � r/ <br /> Owner/Operator: / / Title: <br /> Address hone: <br /> Date: <br /> EH 08 05 <br />