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OCT-26-2010 12:10PM FROM- +9245317885 7-167 P.002 F-406 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTU DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pmperty FACILITY ID# SERVICE RE OUP_ST# <br /> 0 0 <br /> ------------ <br /> ---- n <br /> OWNER IOPERATOR r; clfB AooRESSL <br /> KAISER 'PERM•kN6��. <br /> FAauTrNAMF, <br /> sire AouREsa <br /> rI C rade <br /> SVaai Number <br /> xvir[ blrxtlen � �f NSM,. <br /> Home cr MAILING ADDRESS (if Different from Site dress) <br /> Slesnte+umber Lzmalt st <br /> CITY $TAT ZIP <br /> PHON&#1 MKT. APN0 aEApPLICATIDN7r <br /> s '2-o a - l�a-03�{ <br /> IyHONt2#2 T GC DIr.TI Icr L ocATW4 ccne <br /> CONTRACTOR/SERVI QUESTOR <br /> REQUESTO + DmEcg If 81LMNr AooRE4y <br /> ..l3iJ F-EsNAUE exs <br /> p # 48 <br /> E or hMAIUNG AODRE98 FAX# <br /> STATE IJPj <br /> +� jiY_lr rMG&r-Y2i;;f'UVLEIIGEMENT: 1, the nude 'gtcd propurfy or business owner, operator or authorized agent of same, <br /> ackriewledge that all site and/or pmject specific RQNMHNTAL HFA1,TH DFPXRTME-NT hourly charges associated with this project <br /> r, <br /> or activity will be biped 10 ttte or my business a "dentificd on this form. <br /> I also certify that I hove pmparedthis applic on and that the work to be performed will be done In accordance with alt SAN JOAQUIN <br /> COUNTY Ordinance Codes,Srandardal T and FE BRAL laws• <br /> APPLICANT'S SIGNATU ✓ I}ATt�7 1 <br /> PROPERTY/BusmsowNSR0 PERATORIMANAGER LF OTT=A0THOR126DAGENT <br /> � <br /> �A>�7+uC+1APr is Trot a 14J7I_tJJi;??RR7 r,p.T+a., -f auslAorization sa sign is required TWe <br /> AVT1t409TXATfON TO RELEASE INFORM&3]ON:When applicable,I,the owner or operator of the property located at thin <br /> above site address, hereby Whorize the release of any and all rcaults, geotechnical data and/or environmental/site assessntr_,at <br /> information to the SAN JOAQUIN COUNTY ENVIRONMIWTAL HEALTH DEPARTMENT IS 50011 as it is available and at die same time it is <br /> provided to=or rnq representative. <br /> TYPEOF SERVICE REEMEWMD: <br /> CoLItWre: RECEIVED <br /> SEP 13 2010 <br /> SAC XAQLxN COUNTY <br /> NVIAONMl NTA[. <br /> p HEALTH DEPARTMENT <br /> ACCEPTED BY: 41 E-: e--A- EMPLOYEE#: �' �( DATE' q 13 <br /> (� <br /> ASSIGNED Ta- EMPLOYEE#: i,� QATE' L <br /> T— — --- <br /> Date Sen ace Completed (If alroady completed): SERVICE CODE: piG <br /> Fee Amount; 6 re_vo TAmount Paid Payment Date <br /> I'ayrnent Type Invoicll# Check# Re elvad y <br /> EHD 46-021025 SR FORA(Gilden Rod) <br /> REVISMD 11/1712003 <br /> LZ /Z # Z096L989161 L9 96 06-6Z-OG <br /> ONI S31VI00SSV 3d(Idd Z09TL98916T 0E:60 010Z/6Z/0T Q3AI303d <br />