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BOARO OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Jan,"Culbertson, Pree. City of Lodi <br /> Mary Anna Love,Vice Pyee, 1601 East Hazelton Avenue, P.O. Bos 2009 sen Joaquin County <br /> Patricia E.Vannuccl,Sa<'y. Sen Joaquin County <br /> Tommy Joyce Stockton,California 95201 City of Escafon <br /> Ead Pimentel City of Manteca <br /> Vlaginis Mathews (209) 466-6761 City of Ripon <br /> Daniel L Florae city of Stockton <br /> John D.Mask M.D. Joel Khanna,M.D.,M.P.H.,Dlalrkl Haahh 0e6cer City of Tracy <br /> Gana S.Kraham San Joaquin County <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br /> SITE ASSESSMENT INFORMATION <br /> 4 I , the undersigned owner and/oor" operator oftheproperty and/or facility <br /> located at _'IJ_l //✓e, r1V / it-1 L�iL <br /> hereby authorize �, 1"IOYI lie_ <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 /> Owner/Operator: /d �i�/��/1'� Title: <br /> Address S phone: 9.-�/g7- 3'/0/ <br /> Date : /r&ke'l z /-?n" <br /> EH 08 05 UGT 13 <br />