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01/15/2002 02:43 2093397651 LMH MTC SHOP PAGE 02/05 <br /> 0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 7L FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR Randy CH2CxIfBILLING AaW=13 <br /> FACILiTy NAME --Lodi Memorial Hospital ...... <br /> SrFEADDRESS 975 1 $ Fairmont ii 95240 <br /> Sheet Num ber —Plm—rtion _I- streel City <br /> HOME or MAILINr,ADDRESS (If Different from Site Address) <br /> PO Box 4135 Stmet Number Street Mama <br /> CITY Portland STATE OR zip 97208 <br /> PHONE Xi ExT, APM 9 LAND USE APpe(CATION <br /> 209) 339-7667 <br /> PHONE#2 EXT. BOB DISTRICT LocAnopi Cons <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CH CK It BILuNg.ADDRESSM <br /> BUSINIss NAME Elite IV Contractors PHomEX 4XT, <br /> ( 2091-461-6337 <br /> 14omE Or MAtLwo ADn"s'S 2535 Wigwam Dr FAx# <br /> (209) 461-6342 <br /> crly Stockton STATE Ca zip 95205 <br /> BILLING ACKNOWLEDGEMENT! 1, the undersigned property Or business owner, operwor or authorized agent of same, <br /> acktiowledg(t Oar nil sift and/or prc�jcct specific LNVIRONmr-wrAl.l-ItAvrH DEPARTMP'N'r hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this farm. <br /> I also ccrtily that I have prepared this application and that the work to be performed will be done in accordance With all SAN JOAQI.JIN <br /> COUNTY Ordinance Codes,Standards,STAT(^siliO FEDERAL laws. <br /> APPLICANT'S SIGNATIJRF,, Re an ffitcheu DATr: 10/30/2017 <br /> PROPP,RTY/liri$tNF.SR OWNPKE) OPFP,%TOR/MANIAGFR E3 (YffIFm Atlwolkl=A<,E.N,r CY Of Assistant <br /> nor the BILLIvg PARTY,proofafauthorkrifian tv sign is required ritfe <br /> AurHORIZATION IQ 1JE U, &S.E.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 /> ilifor'llati011 to the SAN JOA00IN COUNTY ENviRoNwr;NTAt.HEALTH DIPAX-rmrtNT as soon as it is available an([at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: r! C kp <br /> r,OMMFNTS: <br /> OCT <br /> 3 1 2017 <br /> ENVIRONMENTIAL HEALTH <br /> 7N r:0 A L-) <br /> AccEwmo BY: EMPLOYEE DATE':— <br /> AssiGNrm To: EMPLOYEE 9! DATE: <br /> Date Service Completed (if already completed); SERVZE CODE: I P I E: <br /> Fee Amount! Anicunt Paid Paym®nt[}ate <br /> Payment Type Invoice# Check# Receivetl By: <br /> —7ccelvet,BY <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />