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BOARD OF TRtlSTEEe <br />N Crow, Praa <br />Earl PvnaMat Vim Pna <br />Tommy Joycq sect'. <br />Jamas F. Cubarbon <br />JoM D. Mast M.D. <br />Virginia Matic" <br />Thomas Sclwrbwt D.V.M. <br />Dagvb Shaw <br />"n+y VA W%. PhD. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E8e1 Hazefton Avenue <br />$1DCk1IM CaMoynia 65M <br />Jool R "W% Y.O. "A" D*TWT NMY" OFFICER <br />SERVING <br />San Joaquin County <br />City of Manteca <br />City of Escalon <br />City Of Loth <br />City of Tracy <br />city of Ripon <br />San Joaquin County <br />City d Slo[kton <br />San Joaquin County <br />AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br />SITE ASSESSMENT INFORMATION <br />1, the undersigned owner and/or operator of the <br />located at Property and/or facility <br />hereby authorize <br />to release any and allS _ <br />analytical results, geotechnical data and site <br />assessment information to the San Joaquin Local Health District <br />as it is available and at the same time it is provided as soon <br />to me or my <br />representative. <br />Owner/Operator: <br />Address Dso r _C <br />Date: <br />Eli 23 041 3/66 <br />AdMNslra6on <br />46a-3100 Cbdca Services EwAronwAn l ►leash <br />466-39M <br />Ak Pollution 469 -3420 �,,y,* .app <br />aFiB-ScyO �:i��g W • W <br />Title: <br />Phone: <br />Public Health Nursing <br />468-3860 <br />aid <br />