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r <br /> SAN JOAQUIN SERVING <br /> LOCAL HEALTH DISTRICT <br /> BOAR© OF TRUSTEES City of Lodi <br /> James Culbertson, Pres. San Joaquin County <br /> Patricia E. vannuccl, Secly. 1601 East Hazelton Avenue, P. 0. Box 2009 City of Escalon <br /> Anthonette van Spronse . StoCkton, California 9M1 City of Manteca <br /> Earl Plmentel City of Ripon <br /> Fern Bugbee 2M/46"781 City of Stockton <br /> Daniel L. Flores City of Tracy <br /> John D. Mast, M.D. San Joaquin County <br /> William J. Wade Jogl Khanna, M.D., M.P.H., District Health officer E,, r <br /> � 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 } � A/ <br /> hereby authorize I j� <br /> to release any and all an 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: <br /> ,,� Title: <br /> Address $ZS �,c� Phone: -5 2— <br /> Date: Z c:7 <br /> EH 08 05 <br />