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HE(;EIVLU <br /> 0 OCT 09 7.015 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST ENVIRONMENTAL <br /> CRIT <br /> -T <br /> Type of Business or Property FACILITY ID III <br /> SERVICE REQUEST# <br /> Hosppital bL�-7 <��'>✓7 � <br /> OWNER/OPERATOR Randy CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Lodi Memorial Hospital <br /> SITE ADDRESS 975 S I Fairmont St Lodi 95240 <br /> SftmtNumber I Dlreew Street Name city 7JD Coft <br /> HOME:or MAILING ADDRESS (if Different from Site Address) <br /> PO BOX 3004 street Number street Name <br /> CITY Lodi CA STATE ZIP 95241 <br /> PHONE#1T APN$ LAND USE APPLICATION# <br /> t 200 339-7667 <br /> PHONE#2T BOS DISTRICT LOCATION CODE <br /> I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECKIf BILLINaADDREss <br /> BUSINESS NAME PHONE# F"' <br /> Elite IV Contractors f <br /> HOME Or MAILING ADDRESSr95,30 F # ) <br /> CITY L,,. ,STATE 174 �JTJP q <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STATE and FEDERAL Ia <br /> APPLICANT'S SIGNATURE: DATE: to/J <br /> IobcS <br /> PROPERTY/BVSINESSOwNERD OPERATOR/MANAGER ® OTHER AUTuORrZEAAGENTia 006-0 <br /> IfAppmCAArT iS not the BILLING PARTY.proof of authorization to sign is required / Titled <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENviRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ry J <br /> TYPE OF SERVICE REQUESTED: „ L¢ 51 �r� t5 3 t r 61 tom&1.1 1/t S� <br /> ROW <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: (G <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed). SERVICE CODE: 1P1 E: �c <br /> Fee Amount: 434( -C.76 Amount Paid (7. Payment Date to ct S <br /> Payment Typev Invoice 4 Check# AYM Received By: <br /> LVED <br /> EHD REVISED 11 1710©3 0 C r Q 9 SR FORM(Golden Rod) <br /> 2015 <br /> SAN JOAQUIN COUNTY <br /> EN"AOMENTEfIEALTt!�P1I#It 1&a <br />