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BOARD Of TRUSTEES SAI4 JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. <br /> City of Lodi <br /> Mary Anna Love,Vice Pres. 1601 East Hazelton Avenue, P.O. Box 2009 San Joaquin County <br /> Patricia E. Vannucci, Secy. San Joaquin County <br /> Tommy Joyce Stockton, California 95201 City of Escalon <br /> Earf PimentelVirgCity of Manteca <br /> Daniel <br /> Mathews (209) 466-6781 City of Ripon <br /> Danl L Fiore. Cfty of Stockton <br /> John D.Mast,M.D. Joel Khanna.M.D..M.P.H.,District Hearth Officer City of Tracy <br /> Gene S.Kraham 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 property and/or facility <br /> located at ,y �� S � <br /> hereby authorize ll <br /> , �-0Ll OkipeN 4—al <br /> 1 <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 /> AA <br /> Owner/Operator: Title: <br /> Address <br /> f)e �LeA5ejey <br /> Addresse4��- <br /> Phone:�yls, �2(,-d677 <br /> C <br /> Date : 7�eA <br /> X <br /> EH 08 05 UGT 13 <br />