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BOARD OF TRust EES SAN J*QUIN LOCAL H1=.ALTH DISTRI4 SERVING <br /> Jame, Culbertson, Pres. City of Lodl <br /> PaIrlCla E. VannucCI, SeC'y. San Joaquln County <br /> AnIhonalla Van Sproneen 1601 East Hazelton Avenue, P. O. Box 2009 City of Escalon <br /> Earl Pimentei Stocl(ton, California 95201 City of Manteca <br /> Fern BupbCity 209/466-6781 y of Stity Ripon <br /> on <br /> Daniel L. Flores ocxt <br /> John D: Mast, M.D. City of Tracy <br /> William J. Wade Jogl Khanna, M.D., M.P.H., District Health Officer San Joaquin County y <br /> Mary Anna Love San Joaquin County <br /> 00422 <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 . / � rr �,�-�j �� / � r � -��' _ '4 <br /> hereby authorize � ( l t <br /> to release any and all analytical results, geotechnical data and site <br /> dssessment 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 /> Owned/Operator: <br /> � �; ����� Title: , <br /> Address� �—� t — Phone: c'c SiG S <br /> Date: <br /> ORIGINAL <br /> EH 08 05 UGT 13 <br />