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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f tb . ik <br /> OWNER><OPERATOR Randy Roehrich <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Lodi Memorial Hospital <br /> a <br /> SITEADDRESS 975 Fairmont St Lodi 95240 <br /> Street Number I Directio treet Name CiLl Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( > , ® 9 <br /> PHONE R EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller <br /> CHECK If BILLING ADDRESS <br /> BuslNEss NAMEElite IV Contractors (209ONE# /993-4267 <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: 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 I have prepared this ppl ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar s,ST E and FEDERALAla <br /> APPLICANT'S SIGNATURE: DATE: U n __ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® OfWce Manager <br /> If APPLICANT is not the BILL/NG 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 sOA <br /> time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: //� fj % i2 '�Ld /� I <br /> COMMENTS: <br /> r ' 201 <br /> R®N C®UN <br /> T/YQEp�M N , <br /> ACCEPTED BY: /q "� EMPLOYEE#: 26 ?v DATE: IQ <br /> ASSIGNED TO: 2 EMPLOYEE e)03 DATE: <br /> Date Service Completed (if already completed): SERwCE CODE: I P 1 E: z�D <br /> Fee Amount: tI.C Amount Pai Payment Date <br /> Payment Type Invoice# Ch k# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />