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SAN JOAQUIN COUNTY E"TRONMENTAL HEALTH DEPARTM,E <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID iI SERVICE REQUEST <br /> m <br /> Long Term Care Pharmacy <br /> OWNER 1 OPERATOR <br /> Evergreen Pharmaceutical of California,Inc. e>teerclf>SuuNrs Ras❑ <br /> FAcamfUtlE Omnicare of Northern California#48214 <br /> SifEADwm 850 <br /> saMtNwo South Guild Ave. Lodi 95240 <br /> stmat Name Zip Code <br /> HOME orMAILINOADDREss of Different from Site Address) <br /> One CVS Drive,MC 2340 <br /> strut Number 81"M Name <br /> CRY Woonsocket STATE RI zip 02895 <br /> PHONE#1 Err. APN# L,ANo UsE APPLICATION <br /> (401 ) 770-4099 <br /> CATION CODE <br /> tW 7 , <br /> PN2 S <br /> TRICT <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REDUESTOR <br /> Omnicare of Northern California#48214 CHECK lf&�,LINGADDRM <br /> BUSINESS NAME Em <br /> Omnicare of Northern California#48214 (401 <br /> �- 401 770-4099 <br /> HOME or MAILING ADDRESS FAX# <br /> One CVS Drive,MC 2340 (401 ) 216-0906 <br /> Cm Woonsocket STATE ZIP 02895 <br /> BILIMG AMNOWLEDGEMENT: 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 /> 1 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 FEDWL laws. <br /> PLICANT'S SIGNATURE: / -(,Mvr DATE: <br /> Paorzm/Busrnass OwmW3 OPMATOR/MANACER36,, OrnER AUT NORM"AGaNT 0• <br /> F. IfdppLIc hT is not the filth vcPAR proof of authorization to sigh is required Title <br /> AUTHOR17ATION TO RELEASE INFOILIXEMON: When applicable,I,the owner or operator of the property located at the <br /> r 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 ENYtRoNM&N7AL HEALTH DEPARTMENT as soon as it is available and at a it is <br /> provided to me or my representative. <br /> TYPE OF SERME REQUESTED: Medical Waste Plan Check <br /> COMMEWT <br /> tijoq <br /> H COU <br /> MTY <br /> gRT�FNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �,? EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE Colm 523 P IE 4501 <br /> Fee Amount: $152 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />