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I T <br /> BoARD,oF TRUSTEES SAN j o.UIN LOCAL HEALTH DISTRI•" SERVING <br /> lames EutGertson, Prme. Clty of Lodi <br /> r:rici■E . Vannuccl, Smc'y. San Joaquin County <br /> P <br /> i6©t East Hazelton Avenue, P. O. Bax 20()9 city at Escaion <br /> Anlhonette Van Spronnen City of Manteca <br /> Earl Pimenlef Stockton, California 9520, <br /> � City of Ripon <br /> Farn BuQdee <br /> 209/466-6701 City of Stockton <br /> Daniel L. Mores City of Tracy <br /> John D: Mast, M.D. <br /> WIIllam J. Wade JoQI Khanna, h1_C7., M.P.H., Dlatr]cI Health ofllcar San Joaquin County y <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 ropert and/or facility <br /> L f <br /> located at '-r/y �. ,/'�"7��.c.•c.% � �= -� ��` <br /> hereby authorize eX—�L <br /> to release any and all analytical results , geotechnical data and 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 /> Owner/Operator {� / Title: <br /> Add ress , _' � 7"cfCrf�� Zi3 phone: Lll� <br /> d� <br /> Date• ' <br /> 0 <br /> FH OB 05 UGT 13 <br />