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'*.O� *ftpi <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> City of Lodi <br /> James Culbertson, Pres. San Joaquin County <br /> Patricia E. Vannuccl, sec•y. 1601 East Hazelton Avenue, P. O. Box 2009 City of Escalon <br /> Anthonette Van Spronsen City of Manteca <br /> Earl Pimentel Stockton, California 95201 City of Ripon <br /> Fern Bugbee 209/466-6781 City of Stockton <br /> Daniel L. Flores City of Tracy <br /> John D. Mast, M.D. <br /> San Joaquin County <br /> William J. Wade Jogi Khanna, M.D., M.P.H.. District Health Officer <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 'I { c7 &4c�.C.tAc_- _I <br /> hereby authorize C-Vcsl.it ; I ,&lwi.— -__---- <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 /> G01-D57k.�S7A7I sZE-AEZ- Ad /�� /d�•'� <br /> Owner/Operator: —Title: <br /> Address ?_0 d7ax- ---Phone: 3G4-'t-7 <br /> S' L Y I-- <br /> Date:Date: <br /> EH 08 05 <br />