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BOARD of TRUSTEES SAN JOAQUIN LOCAL HEALTHPISTRICT SERVING <br /> James Culbertson, Pres. �ICity of Lodi <br /> Patricia E. Vannucci, sec'y. 1601 East Hazelton Avenue P. O. Box 2009 San Joaquin County <br /> Anthonette Van Spronsen City of Escalon <br /> Earl Plmentei Stockton, California 95201,'. City of Manteca _ <br /> Fern Bugbee209/466-6781 ?I City of Ripon <br /> Daniel L. Flores i City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade Jogi Khanna, M.D., M.P.H., District Health Officer San Joaquin County <br /> Mary Anna Love It San Joaquin County <br /> i <br /> I� <br /> 3I <br /> 1i <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br /> SITE ASSESSMENT INFORMATION <br /> i' <br /> F <br /> I , the undersigned owner and/or operator of the property and/or facility. <br /> i <br /> located at 41,34/ S • Fr�•�� *-7 r S-7`; S7`1,c-KtTz;n (r/-- 5s��L <br /> it <br /> hereby authorize y i Ok P _ 4 <br /> it <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 /> +i <br /> Owner/Operator: _ Title: �Yu ✓��'� <br /> Address /� �-� ��r}��Phone: �� <br /> — c.���-► Cry 9 s��� �' _ �� _ <br /> Date: <br /> tr: <br /> i <br /> �1 <br /> 3� <br /> EH 08 05 <br /> f' <br />