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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA CDDa 513 S R W78 3Z) <br /> OWNER/OPERATOR <br /> Randy CHECK If BILLING ADDRESS <br /> FACILITY NAME Lodi Memorial Hospital <br /> SITE ADDRESS 975S Fairmont Lodi 95240 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO Box 4135 Street Number Street Name <br /> CITY Portland STATE OR ZIP 97208 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 339-7667 031 oda <br /> PHONE#2 EXT BOS DISTRICTLOCA TION CODE <br /> C5rl <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Megan Mitchell CHECK ifBILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE# EXT. <br /> 209 461-6337 <br /> HOME or MAILING ADDRESS 2535 Wigwam Dr FAX# <br /> (209) 461-6342 <br /> CITY Stockton STATE Ca 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: Megan Mitchell DATE: 10/30/2017 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 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, 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 *1/8kJ11ssess#iertg <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avai t1he�a�tl ftf(e t, s <br /> provided to me or my representative. <br /> CE REQUESTED: u R `0 IT 11 201 <br /> BIOMED <br /> 13 1 7017 ENVIRCKMENTAL M EALTH <br /> DP <br /> ? c € yy <br /> N JOAQUiN CCUWN +. . t 9�P,IL7-N <br /> ENVIRONMENTAL <br /> FA.ITN DEPARTMENT <br /> ACCEPTED BY: El/�' �ck- EMPLOYEE#: CT,uc DATE: i© ,'- <br /> ASSIGNED TO: "` EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: J--)502 <br /> Fee Amount: , Amount Paid Payment Date 3� <br /> Payment Type Invoice# # ec ived By <br /> S : <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />