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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> City of Lodi <br /> Jame.CuRmison.Pm. <br /> Mary Anna Love,Vice Pres. 1601 East Hazelton Avenue, P.O. Box 2009 SanJoaquin <br /> Joaquin County <br /> PaVicla E Vannutd.S«'y. a E«alon <br /> Ternmy Joyce Stockton,Calffomla 95201 <br /> City of Maniac* <br /> Ead PltneniN qty a Ripon <br /> Virginia Ma"wa (209) 468-8761 City of Stockton <br /> Dania!L Fiore$ City of Tracy <br /> Jam D.Mas,M.D. Jog!Khanna,MA,M.P.N.,WAW Health 01/oer San Joaquin County <br /> Gem <br /> S.Kraham <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br /> SITE ASSESSMENT INFORMATION <br /> 4 I , the undersigned owner and/or operator of the property and/or facility <br /> located at 1400 �� r au T <br /> hereby authorize (I(�U� A�Fi(C - LAS Y-Y�pF tff 0 <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 /> 4 Owner/Operator: Title: <br /> Address Phone: <br /> lL <br /> Date : <br /> EH 08 05 UGT 13 <br />