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Jomoe CulbortoOn �F'rna. A! �.nry ll, �, 1 P 11'r IIS'6y�,�y(h}-TIUML I 1 I S�t•x n Ilk,1 SERVING <br />F slrlcla F.. Vonnucct-SoC`�': City of Lodi <br />AniP�orivilo Van Spronaon x,01 Ea$l NazellGpo IAV,onue,. P, 0. ©ox Son Joaquin County <br />Furl Pimontal City of Gecalon <br />Stock9on, Callfornia 9`i201 CI(y of Mnntaca <br />rn!at f_. Toros 2091466-6701 City of Ripon <br />rc^m 0. Masi, MA - City of SlDcklon <br />City of Tracy <br />^Jtt!larn .9. Nlndo Jopl Khanna,'M n ; M.p.M., DiolrIct lionlih Officer S <br />P.^.ery f,nna Lovo an Joaquin County <br />San Joaquin County <br />11080 <br />i <br />AUTHORIZATION TO RELEASE ANALYTICAL RE SULTSGEOTECIINICAL DATA AND <br />SITE ASSESSMENT INFORMATION <br />I, the undersigned owner and/or operatpr of the property and/or facility <br />located at e'JQ % N. <br />hereby authorize <br />to release any and all analytical r-o"I";'geoteehnical data and site <br />assessment information to the San Joaquin local Health District as soon <br />as it is available and at the sante time it is provided to me or my <br />representative. <br />Owner/Operator: i Title:— <br />Address <br />itle:—Address —'I e9 -7 �/.e��i tib/ Phone: <br />Date: <br />ORIGINAL <br />