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O - <br /> SERVING <br /> BOARD OF TRUSTEESSA JOAQUIN LOCAL HEALTH DIS ICT City of Lodi <br /> Jamas Culbertson, Pres. San Joaquin County <br /> Patricia E. Vannucci, Secy. 1601 East Hazelton Avenue, P. O. Box 2009 city of Escion <br /> • Anttronette Van Spronsen ` city a#~ <br /> Sari'Plmeniel Stockton, Cal Ifvmia 95201 ��.r�r�� y: City ofRipon <br /> Fern Bugbee 209/46"781 '"'" 1'� city of Sioci<ion <br /> Daniel L. Flores City of Tracy <br /> John D. Mast, M.D. _ San Joaquin County <br /> William J. Wade Jogi Khanna, M.D., M.P.H., District Heal car <br /> ��� � ��'15an Joaquin County <br /> Mary Anna Love <br /> AUTHORIZATION TO RELEASE ANALYTICAL RESULTS, GEOTECHNICAL DATA AND <br /> .-.stff-ASSESSMENT -i t ORM -eN - <br /> I, the undersigned owner and/or operator of the property and/or facility_ <br /> located at 2500 West:- Lodi. Avenue, Lod' <br /> hereby authorize Applied GeoB stems <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 /> Owner/Operator: Title: <br /> Address A ' Phone; Z/ - z'� <br /> Date: <br /> EH 08 05 <br />