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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST 0 <br /> L <br /> OWNER I OPERATOR <br /> Randy CHECK If PJ NgAp-qms 0 <br /> FAcLnY NAME Lodi Memorial Hospital <br /> SITE ADDRESS 975 Lodi <br /> ft"t Num bo I Di S Fairmont 1 95240 <br /> CW1 Zia C <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> PO Box 4135 Number Streat NUm <br /> STATE zip <br /> CITY Portland OR 97208 <br /> PHONE#i EXT. APN# LAND USE APPLICATION# <br /> ( 209) 339-7667 1 <br /> PHONE 92 ExT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQuESTOR Megan Mitchell CHECKlf BILLING ADDRESSID <br /> BUSINESS NAME Elite IV Contractors PHONE# Exr. <br /> ( 2921 MIME <br /> HOME or NWLING ADDRESS 2535 Wigwam Dr FAX# <br /> (209) 461-6342 <br /> CITY Stockton STATE Ca zip 95205 <br /> J!ILLING 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: Alum Itfitzhea DATE: 103=2 <br /> PROPERTY I BUSINESS OWNER13 OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT EX Office Assistant <br /> If 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: n EZ U C. EC <br /> COMMENTS: <br /> NP �t 5 2017 <br /> ENVIRONWE-NTAL FI LT <br /> D E PA P,T 11 A p <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: --TP I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />