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BARD OF 1 RU.S'.EES SAN JO�UIN LOCAL HEALTH DISTRICJI SERVINo <br /> City of Lodi <br /> rme: Cdbenson, Pres. San Joaquin County <br /> Veticia E. vannu«I, sac'y. - 1601 East Hazelton.Avenue, P. O. Box 2009 City of Escaion <br /> ;nt.honette Van Spronsen City of Manteca <br /> ;srflpimental - Stockton, California 95201 City of Ripon <br /> 'ern BuOoee 209/466-6781 City of Stockton <br /> anial L. Floras City of Tracy <br /> ohn D: Meet, M.D. <br /> imarn J. Weds Jopl Khanna, M.D., M.P.H., District Health Officer San Joaquin County y <br /> San Joaquin County <br /> i <br /> ary Anna Love <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 �/D/ ��� ✓C� �� ' -- —7 <br /> hereby authorize <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 /> Title: CJ <br /> Owned'/Operator:+ ,q <br /> Address <br /> t • j - <br /> � c <br /> Date: f I� � <br /> ORIGINAL <br /> . a <br /> EH 08 05 UGT 13 <br />