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SAN JOAQUIIWUNTY ENVIR6NMENTAL HEALTIWPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Kaiser Permanente - hospital <br />FACILITY ID # <br />V <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />Kaiser Permanente <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME Kaiser Permanente <br />EXT. <br />SITE ADDRESS 7373 <br />Street Number <br />Direction <br />West Lane <br />I <br />Street Name <br />Stockton -T <br />city <br />95210 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />(209 ) 476-5408 <br />APN # <br />STATE CA <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />P / E: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Elite Four - Chuck Dowdy <br />34 <br />CHECK if BILLING ADDRESS El <br />BUSINESS NAME Elite Four <br />PHONE# <br />EXT. <br />wy <br />209 <br />461-6337 <br />HOME or MAILING ADDRESS 2535 Wigwam Drive <br />ACCEPTED BY: /i% <br />i1 <br />FAX # <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: t /( <br />( 209 ) <br />EMPLOYEE M <br />CITY Stockton <br />STATE CA <br />ZIP 95205 <br />BILLING ACKNOWLEDGEMENT: 1, 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 laws. <br />APPLICANT'S SIGNATURE/ DATE: /d^ 3 t 2 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT C:W <br />!(APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. <br />TYPE OF SERVICE REQUESTED: <br />34 <br />COMMENTS: <br />RECEIVED <br />SEP 2 8 2012 <br />wy <br />BMRO�NNENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: /i% <br />i1 <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: t /( <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: '~ <br />Amount Paid <br />Payment date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />