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I ' BOARD OF TRUSTEES ?N JOAQUIN LOCAL HEALITH D►�__'"RICT SERvifra <br /> James Culbertson, Pres. L cityof Lodi <br /> Patrlcia E. Vannucci, Sec'y. '' '. <br /> Anthonette Van Spronsen 1601 East Hazelton Avenue, P. 0. Box.2009 San Joaquin County <br /> imentel City of Escalon <br /> Ear! P <br /> Stockton, California 95201 City of Manteca <br /> Fern Sugbee <br /> City of Ripon <br /> Daniel L Flores 209/466-6781 <br /> City of Stockton <br /> John D. Mast, M.D. <br /> Will <br /> iam J. Wade Jogi Khanna. M.D.. M.P.H.. D(strici Health Officer San Joaquin County <br /> City of Tracy <br /> j Mary Anna Love <br /> i San Joaquin County <br /> I 1 <br /> i <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br /> SITE ASSESSMENT INFORMATION # <br /> I i IL <br /> I , the undersigned owner and/or operator of the property and/or facility j <br /> j: <br /> located at 1A <br /> hereby authorize �.eG;r=D,tn /�4 �4�1��,o�! i sy <br /> to release any and all. analytical results, geotechnical idata and site <br /> I <br /> assessment information to the San Joaquin Local Health District as soon- <br /> as <br /> as it is available and at the same time it is provided to me or my { <br /> representative. <br /> r i <br /> Owner/Operator Ti tI e.", <br /> Address �D_' �Ov�y 41re��c/ Phone. ��.� .4'720 i <br /> I � t <br /> i <br /> Date: <br /> p <br /> it <br /> it <br /> IF f <br /> i, <br /> f f' <br /> EH 08 05 <br />