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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Patricia E. Vannuccl,'Se0y. San Joaquin County <br /> Anthonette Van Sproneei( 1601 East HBZBItOn Avenue, P. O. Box 2009 City of Eacalon <br /> Earl Plmentel Stockton, California 95201 City of Manteca <br /> Fern Bupbee 209/486-8781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade Jog[ Khanna, M.D., M.P.H., District Health OfficerSan Joaquin County <br /> Mary Anna Love f�e' �San_Joaquin County <br /> h1AR <br /> 1 3 9989 <br /> PERrV11 /S'ERVECES�Ali <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 <'as' t� p'J Y cGplI -e �TflCKNm 0 <br /> hereby authorize _ 1 I (n�ATE� L A Y)lO0 �T"D <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: 41 Title: <br /> Address SLS Phone: <br /> Date: -1. —�� <br /> rl: <br /> p <br /> EH O8 05 <br />