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+wn. ►... SA,,, JOAOUINLOCAL HEALTH DISTrfCT <br /> -�.. E. v.nn,.oq. 6.c'y_ <br /> -' ft- eft van sp"on0.n 1ti01 East Hatallon Avenue, P. s0tvwa <br /> E•� �Irnantaf O. Box 2009 G4 of LoJ1 <br /> f'r* auoh.a SlocMon, CallltNnla 95201 S•n Jo.auto ep�ly <br /> Oanlal L pwH C4tyof Eaulon <br /> John 0. Mut, M.O. 209/465$781 City of Manl•Ca <br /> ww"m J. Watt* Gly of Alpon <br /> Mary Anna Cow Jupl Khanna- M-o„ M.1•.1t., 0111rkt H•atlh Oflkar Cltyof S1tc}ton <br /> City of Tracy <br /> San Joaquin County <br /> San JoaQuln County <br /> AUTHORIZATION TO RELEASE <br /> SITE ASSESS SITE <br /> RESULTS, GEOTECHNICAL pgTq <br /> �� INFORMATION AND <br /> I, the undersigned owner and/or operator of the property and/or facility <br /> located at <br /> 3`3 W c--s C H,au c—n_ <br /> hereby authorize VA S7-0c O^j CA <br /> FUS <br /> to release any and all analytical results <br /> assessmrmation to <br /> ent info the San Joaquin Local geotechnical <br /> Local HealthDistrictata dasisoon <br /> as it is avaf]able and at the same time it is provided to mor my <br /> representative. <br /> OwneF;OperdLor: <br /> Address Title: <br /> `33� 1A1E Cty,,W - �t= <br /> 7� W4,/ Phone: <br /> Date: _ <br /> vA <br /> t� <br /> i <br /> H 08 05 UGi 13 � � <br />