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- BOARD of IAUSIEES S,*JOAQUIN LOCAL HEALTH DISOCT SERVING <br /> K• City of Lodl <br /> Jame, Culbertson. N.I. <br /> Pa]rIU, E. Vannuccl. Secy. Sen JoaQuln ,colon <br /> Anthonelte Ven Splonsen <br /> 1601 East liazellon Avenue, P. O. Boz 2009 city of E,celon <br /> E e,I Plmentel Stockton, California 95201 City of Manteca <br /> Fern BupUee City of Ripon <br /> 209/466-6781 city of Stockton <br /> Daniel L. Fiore! <br /> John D. Mast. M.D. Cityol�recy <br /> wimam J. Wade Jopl Khanna, M.D., M.P.H., District Health Officer Sen Joaquin County <br /> Sen Joaquin County <br /> -.Iary 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 /�6 / e 1I? <br /> hereby authorize S o ,�__� �f-/f lyJfl�e.2 64TVto release any and all analytical results, geotechnical data nd 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 /> Ownef/Operator: Te 12 ion C h-te S Title: ASsY-. rtes± <br /> Address /_�) 6.r S. L , eoc'j 51. Phone: V6,2-- //eo <br /> Col � <br /> Date: <br /> 1H 08 05 UGT 13 , <br />