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+- - SERVING <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT City of Lodi <br /> James Culbertson, Pres. San Joaquin County <br /> Patricia E. Vannuccl, Sec!Y- 1601 East Hazelton Avenue, P. O. Box 2009 City of Escalon <br /> Anthonelte Van SpronseiStocktonCalifornia 95201 City of Manteca <br /> , <br /> Earl Plmentel City of Ripon <br /> _ Fem Bupt»e 209/466-6781 City of Stockton <br /> Daniel L. Flores City of Tracy <br /> _ John D. Mast, M.D. San Joaquin County <br /> William J. Wade Jopl Khenna, M.D., M.P.H., District Health Officer San Joaquin County <br /> Mary Anna Love <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 <br /> L. 4 (0 & 1-1�� 11� -^) <br /> hereby authorize ba 't • wP'P 1 p'd s <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 /> STRT- �'FrJSWJ/� <br /> Owner/Operator: Title: V✓ / <br /> Address c �D Phone: <br /> / i c f7TL. <br /> 221Z <br /> Date: <br /> Date: / 2- l> <br /> � � a <br /> p . <br /> EH 08 05 <br />