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•• JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> DOARD OF TRUSTEES City of Lodi <br /> James Culbertson, Pres. San Joaquin County <br /> Patricia E. Vannuccl, Secy. 1601 East Hazelton Avenue, P. O. Box 2009 City of Escalon <br /> Anthonette Van SpronsenCity of Manteca <br /> Earl Plmentel Stockton, California 95201 a"� ;' '%" City of Ripon <br /> Fern Bugbee 209/466-6781 's `' <br /> Daniel L. FloresCity p„1 City of Stockton <br /> John D. Mast, M.D. ,' q <br /> William J. Wade Jogl Khanna, M.D., M.P.H., District Health Officei `. San Joaquin County <br /> uiof Tracy <br /> San Joaquin County <br /> Mary Anna Love HEALTH <br /> ENVIROMENTAL <br /> F ERMII/SERVICES <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 10S'c? !✓, G)"112g roc/p ee� 1Ltoa"i2 /0% e4 . <br /> hereby authorize �`�/ �o l��p �� ��'r 6 7��< 'es <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 /> Owner/Operator: Title: <br /> Address o / /���� Phone: <br /> 61 74 <br /> Date: �2 1 AICE <br /> EH 08 05 <br />