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r +RE <br /> ED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OCT 10 2016 <br /> SERVICE REQUEST IW, <br /> Type of Business or Property FACILITY ID# ENVWWRfAL HE OtLTH <br /> Gas Station �A DEPARTMENT <br /> OWNER/OPERATOR CHECK H BILLING ADDRESS <br /> Randy <br /> FACILITY NAME Lodi Memorial Hospital <br /> SITE ADDRESS 975 S Fairmont Lodi 95240 <br /> Street Number D!mtion treet Name G 1 Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 <br /> EXT• APN# LAND USE APPLICATION# <br /> ( 209 ) 339-7667 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK If BILLING ADDRESS <br /> PHflN20 # 461-6337 Ems' <br /> BUSINESS NAME Elite IV Contractors <br /> HOME or MAILING ADDRESS FAx# <br /> 2535 Wigwam Dr ( 209 ) 461-6342 <br /> STATE Ca ZIP 95205 <br /> CITY Stockton <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 1 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,STATEandFEDERAL laws.�A <br /> APPLICANT'S SIGNATURE: A4W'M'wlk-� DATE: 1917/2016 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13OTHER AUTHORIZED AGENT 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 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: Install 5 sump monitor ports for DW sump communication inspection <br /> COMMENTS: <br /> RFcF� Hr <br /> Oct I 1 0 <br /> S4N,,a4 ? <br /> HSL 4117 <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1 a U <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> e- <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: �'Q Amount Pa [� w Payment Date <br /> Payment Type L5,,j Invoice# Che # �Llb1s3 Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />