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R <br />BOARD OF TRUSTEES <br />SAN <br />JOAQUIN LOCAL HEALTH UfST T <br />m <br />James Culbertson, Prea. <br />SERVING <br />Patricia E. Vannuccl, Secy. <br />City of Lodi <br />Anthonette Van Spronsen <br />1601 East Hazelton Avenue, P. O. Box 2(3(19 <br />San Joaquin County <br />Earl Pimentel <br />Stockton, 952D1 <br />City of Eacalon <br />Fern Bugnee <br />City of Manteca <br />Daniel L. Flores <br />209/466-6781 <br />City of Ripon <br />John D. Mast, M.D. <br />City of Stockton <br />William J. Wade <br />Mary Anna Love <br />Jogi Khanna, M.D., M.P.H., District Health Officer <br />City of Tracy <br />San Joaquin County <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 property and/or facility <br />located at <br />hereby authorize <br />to release any and all analytical results, geotechnical data and sitey <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 />Owned/Operator: S. (It] e. <br />Address r �7 ,�� - D�-,�e't,�,-j'd•Y <br />Phone: <br />Date: .w <br />I <br />EH 08 05 UGT 13 <br />