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BOARD OF TRUSTEES SA`T JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> ,James Culbertson, Pres. <br /> Patricia E. Vannuccl, Secy. City of Lodl <br /> Anthonette Van Spron,en 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Earl Plmentel Stockton, California 95201 City of Escalon <br /> Fern BupDee City of Manteca <br /> Daniel L. Flores 209/466-6781 City of Ripon <br /> John D. Mast, M.D. City of Stockton <br /> City of Tracy <br /> Wllllam J. Wade Jopl Khanna, M.D., M.P.M., District Health Officer San Joaquin County <br /> Mary Anna Love 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 propert and/or facility <br /> located at �> <br /> hereby authorize �jgr/jGJ.rf j� ��/e5-F <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. Q �` <br /> Owner 0 erator• �� � / • r <br /> P � Tit titi <br /> Addres f; Ci tV _ Phone: 3,3 `f <br /> Date: /( 00 <br /> EH 08 05 <br />