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"MAY 30 2003 1 : 34PM RISER PERMRNENTE STOCKTO 20765137 p, 2 <br /> MRY 30 2003 1 : 0 p. 2 <br /> SAN,JOAQUIN COUN'T'Y I:NVIItONMLNTAL HLAL'1'H DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID N SERVICE REQUEST a1 <br /> r <br /> 00 <br /> 2 0 - 5 R 00 3 0 `7 <br /> OWNS OPERATOR CHECKII f,!LLwD A00RE5S <br /> FAGLT/KAvE ,/ <br /> (� l <br /> SITEAD08ESS <br /> i <br /> r7, $Irrol Nvmper Ir P � h <br /> HC HE or MAILING ADORess (it Dllferent from Si le Addre::) <br /> INum r N. <br /> CITY STATE LP <br /> PHONEY 1 . F r• APN Y LAND Use Ar'PUCATIOH N <br /> PHONE Y2 E.r, Dos DGMICT 1.0 ATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR CNE CK 1I.j"L"QAjLALUP <br /> PHONE A E n' <br /> Bus:NEss NAME <br /> ATO <br /> KpVE or MAILING ADDRESS FAx N <br /> C STATE/yI ZIP <br /> Blt,LING AGKNOWLBDGCMENT: J, the undersigned property or business owucr; operator or authoeized agenf of same, <br /> ocknowlcdge that all silt and/or project specific ENVIRONMENTAL HEALTH DCPAIITIVCWlIourly charges associnicd with this project or <br /> aclivily will be billed to nIe or my bwin=as identified on this farm. <br /> [ also cutify/hal 1 have prepared lhiS apPlicat'o nd (hot the work io be performed will bedono in accordance w[th,all SAN JOAQUW <br /> COUNTY Ordinance Codc.I,Sfand s,S nd F GRALIawS. <br /> A'PLICANT'S SIGNATU DAT13: Q <br /> 1'uomuw/UusimW OWNF.I[ QPLIIAT x/MANAGau ❑ QTII6rp1 AUnIORrrxD.AGBNT❑ <br /> If APt,UCANT s riot Il,c UILL/_NG PAR7z.proof rIN. <br /> AUTHORI7ATIQN TO RE CASF INrORMATI : When applicable,1;the owner or operator of the property Totaled at Qu <br /> above site address: hereby authorize the release of any and all results, geotechnical data and/or envirorn»cnAtonl/�'I,(q'�sscssmcnt <br /> informalion (0 the SAN JOAQUIN COU.NPY ENVIRONMENTAL HCAL7H DEPARTMENT AS soon as it Is available ag \� t�ffim it is <br /> provided to me or my rcpresentativ//e. <br /> TTPE CF SERVICE REQUESTED: / 003 <br /> COMMENTS: - .. `�`r GGUN S <br /> NSERV�p\S N <br /> ' QU NhEN P�NEPZN <br /> EN`I <br /> AP PR DYED BY: EMPLOYEE 0: AV DAVE., r <br /> AsSIGNED'TO; <br /> EIIt DATE: <br /> Data Servico Comp lad (if alreadycomploted): swror,.00t l P/'E; Q <br /> Fee Amount: D ,AmounIpaid ��b��t?b Payment Date <br /> Paymanl Typc Involas# Ctwck# J `o lecnlved By: <br /> E+D�rwl-025 / SERVICE REOIIEST FORM <br /> REVISE)65-02 <br />