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BOARD OF TRUSTEES SAN OAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Patricia E. Vannuccl, Secy 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquln County <br /> Anlhonetle Van Spronsan City of Escalon <br /> Earl Plmentel Stockton, California 95201 City of Manteca <br /> Fern Bupbee 209/466-6781 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 4nns 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 <br /> hereby authorize [l4A%.LJt� 9j Vt>Qdy/i i~r✓ .' S�'►r1 �5 °'tom <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: , , z � iy Title: L ` •L/ <br /> Address ��/ 6t/. �,� 'd--'00L Phone: : —�� <br /> Date: <br /> EH 08 05 UGT 13 <br />