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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Av;, <br /> OWNER/OPERATOR Randy Roehrich <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Lodi Memorial Hospital <br /> SREADDRESS 976S Fairmont St Lodi 95240 <br /> Street Number Direction I Streeti i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Strsat Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) ) d 'i <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEElite IV Contractors PHONE# /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: 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 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 and FEDERAL la <br /> APPLICANT'S SIGNATURE: 1 DATE: U <br /> PROPERTY/BUSINESS OwNER❑ OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT® ice Manager <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 s Ime it is <br /> provided to me or my representative. �Vk <br /> TYPE OF SERVICE REQUESTED: lit S t2 G/" E-1 T I V <br /> COMMENTS: t +�s <br /> 19 ?01 <br /> Em7l Q""N C <br /> HFACTHO p4 r UN <br /> N <br /> ACCEPTED BY: EMPLOYEE M ?i6 -7 O DATE: �O / <br /> ASSIGNED TO: 2 JAZ � EMPLOYEE M '!�10 3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 7-3O 9 <br /> Fee Amount: tI S(, Amount Pal d� Payment Date �q 8 <br /> Payment TypeVj'.�,pInvoice# Ch k# .31HReceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />