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• z <br /> g F <br /> - <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST APR 14 2016 <br /> Type of Business or Property FACILITY-1f ""SERVICE REQUEST# <br /> Hospital FA <br /> OWNER i OPERATOR <br /> Randy CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Lodi Memorial Hospital <br /> SITE ADDRESS S Fairmont St 95240 <br /> 975 Street Number Direction Stree Name Lodi ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> I <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 ) 334-3411 <br /> PHONE V ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK if BILLINGADDREssE) <br /> BUSINESS NAME PHONE# Ext. <br /> Elite IV Contractors 209 461-6337 <br /> HOME Or MAILING ADDRESS FAX# <br /> 975 S.Fairment St. ( 209 ) 461-6342 <br /> CITY Lodi STATE CA Zip 952240 <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 HE.AL'rli 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: DATE: 4/14/16 4/14/16 <br /> PROPERTY/BUSINESS OwNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I@ Office Manager <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sigit 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: TLS Software UPGrade and Cold Start ' 24 Y <br /> COMMENTS: ITItFC<C`w�V;P' <br /> 4pR �f <br /> ?416 <br /> y44iNo <br /> cb4,, <br /> ACCEPTED BY: EMPLOYEE M DATE: 4/H/i Jp <br /> ASSIGNED TO: (J � �� EMPLOYEE DATE: Vi Lf. Ito <br /> Date Service Completed (if already completed): SERVICE CODE: s���8 PIE; Z3oLl <br /> Fee Amount: 1�.� Amount Pal 3 Payment Date `t <br /> Payment Type Invoice# Ch e.A# ( I b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />