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SAN JOAQUIN"OUNTY ENVIRONMENTAL HEALTF-DEPARTMENT <br /> SERVICE REQUEST <br /> ---f- <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Medical Center FA 0 rj 3 7(� �; c�C S`t:3 <br /> OWNER/OPERATOR <br /> St. Josephs Medical Center nO CHECK If BILLING ADDRESS <br /> x <br /> FACILrrr NAME <br /> St. Jose h's Medical Center <br /> SITE ADDRESS <br /> 1909 Cemetar� Lane Stockton 95204 <br /> Street Number Direction treet Name CI ZI Cotla <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number at Name <br /> CITU STATE Zip <br /> PHONE#1 EaT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONEY EaT. BOS DISTRICT <br /> LOCATION CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Chuck Dowdy CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E.T. <br /> Elite IV Contractors 209 1 461-6337 <br /> HOME or MAILING ADDRESS FAX# <br /> 2535 Wigwam Drive ( 209) 461-6342 <br /> CITYStockton STATE CA Zip 95205 <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 perfonned will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F DERAL lay . <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPBATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Assistant Chief Engineer <br /> I,fAPPLICANT is not the BILLING PARTY.proof of authorization to sign is required Title <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 t0 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: CA 1 RECEIVED <br /> COMMENTS: OCT 19 2012 <br /> 841 JOAQUM Cot1NTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEIfr <br /> ACCEPTED BY: G/C� EMPLOYEE#: DATE: /::, <br /> ASSIGNED TO: G EMPLOYEE#: DATE: I -)--- <br /> Date Service Completed (if already completed): SERVICE CODE: 0 P1 : 2,30 <br /> Fee Amount: —j 7'5 1 Amount Paid 3''S� Payment Date )p <br /> I �q1 I Z- <br /> Payment Type Invoice# Check# �35 ) Received By: Uy <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />