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Nov 16 12 11:30a Elite IV Contactors 12094616342 p.2 <br />Nov. 14. 2012 1.35FM ban aW n t,oun tY1 <br />aAN,1QAQu VX1 Y r,Nvt>tt NTALHEA.JLTHM <br />\d, �' <br />eEvi6QUEST <br />��1j'i Y...•� t l.. l <br />FACILITY In 9 SERVICE REQWST g <br />Type of Business <br />or ProyCas�Pe�reTnte <br />• <br />-hospital <br />Ea 1 OPERATOR Kaiser Permanente <br />Fav E Kalser Permanente <br />5to <br />WrAt""917373 West Lane <br />Aaw um <br />Now or MAti.RVG ADDRESS In Mftmnt from Mte ) <br />Riftqt <br />STA76 <br />CITY <br />EXT. <br />t�'NONES'! <br />APN $ <br />LAND USE <br />1209 ) 476 -WO <br />PRONE #2 WT. <br />I ) <br />t30S <br />T Elite Four - Chuck Dowdy <br />?I ran T9521Q <br />r fe <br />sv c <br />A SUCATION-0 <br />it B <br />r <br />INt Me# — exY, <br />EWSWEss NAME Elite Four , ;9 461-6337 <br />L::.�_— <br />Norm or M Luria ADOR FM 2535 Wt9Wam Drive 17A t` <br />1 1]9 i <br />c:tTr Sn <br />STATE ` t� zip 95205 <br />_ . <br />)fL A O EDG N 1, the undersigned property or business owner, tip gator or authorized agent of some, <br />aelmow a that all site ar project specific rarvuto Al TH DEPAR he it y es associated with this project <br />or activity will be billed to mic or my bushms as identified on this folm <br />I also opt* that l have priepared this appljcatjon and that the we* to be pofurmed will be do v in =ordance with all SAN JOAQ1'IN <br />COUNTY Ordinance Codes, Standards, STATE and FEVEt L laws. <br />APPLICANT'S SIGNATURE EIA 1tt fid" 31 / <br />IMOPUTT / BUSIN"SowraltO opaA= i MAKAoin,13 0T=PtAUM0N= AG1EN J <br />JfAPPLrCANT rs rat the B1t AR f of authoriZgWOn to sign is repair' I rime <br />A>7't%10 Tt®N 1'O i l:ASE rM TION: Whm applicable, 1, the owner or a isrotor of the property at the <br />above site Address, bereby ze the release of any and all results, geoWmical dhtt andtor eavironmentaVsite assessment <br />information to the SAN JOAQM COUNTY ENVIRONMENTAL HEALTH D"ARTMENT as soon is t is available and at the same time it is <br />provided to ane or my represerdal&# _ <br />ttAmp <br />, %L., M; <br />J.. <br />711 <br />. <br />! .v f <br />