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Jame, Cnlbari,on, Pres. SANrQUIN LCjCAL HEALTH DISTRICT <br /> P,Iflce E. Vannuccl, Secy. <br /> Anthonelte van Spron,en 1601 East Hazelton Av • SERVING <br /> Fern <br /> Butibeel Avenue, P. O. BOX 2009 City of Lodl <br /> Fern Bupbae Stockton. California 95201 SanJoaqulnCounty <br /> Daniel L. Flora, City of Escalon <br /> John D. Mast, M.D. -�781 City of Manteca <br /> William J. Wade City of Alpon <br /> Mary Anna Lova Jopl Khanna, M.D., M.P. City of Stockton <br /> H., District Health Officer City of Tracy <br /> San Joaquin County N, <br /> 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 <br /> Ccer <br /> located at roperty and/or facility <br /> /7 <br /> hereby authorize 952 c <br /> C /�� t 1 <br /> �Cl1 1, Z" <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 /> Address Title: . <br /> Lc) Phone:( Ly If <br /> o _ `LS-02 i� / <br /> ' R <br /> Date: ,— F— 1 :3 � <br /> , <br /> EH 08 05 UGT 13 <br />