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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL$EALT E ED-V <br /> x <br /> SERVICE REQUEST <br /> 4 <br /> Type of Business or Property FACILITY ID# A&ftE RV-QOW# <br /> l <br /> OWNER/OPERATOR Randy Raehrich 1 <br /> RQIm "WON <br /> FAcsarrNAME Lodi Memorial Hospital <br /> SITEADDRESS 975 S Fairmont St Lodi 95240 <br /> treet Number I Djuiction 21mat Noe Zia Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Numb®r Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( } 1077 Q 0/ <br /> PHONE#2 Pxi. BOS DISTRICT LOCAMON CODE <br /> ( 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller �— <br /> CNEGet If BILLINt3 ADDR ss <br /> BUSINESS NAME Elite IV Contractors # <br /> 209 461-6337 /9934267 <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 and FEDERAL Is /' <br /> APPLICANT'S SIGNATURE: / DATE:� ls <br /> PROPERTY/BUSINESS OwNERM OPERATOR/MANAGER ❑ OTHER AUTHoRizEDAGENT ' O ice Manager <br /> IfAPPGiGRN7 isnot JheRJLGJNG PARTY proof of authorization to suet is required Tina <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 environmentallsite assessment <br /> information to the SAN JOAQuiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the We it is <br /> provided to me or my representative. T^ ]' <br /> TYPE OF SERVICE REQUESTED: 0/ 7 R `ET <br /> COMMENTS: <br /> 1J, <br /> ZO' <br /> H M'iROro c0U <br /> �4CTHp�pMR�� <br /> N <br /> ACCEPTED BY: 'UL EMPLOYEE#: 26-70 DATE: 10 $ <br /> ASSIGNED To: � EMPLOYEE#: j°j p 3 DATE: s <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: <br /> Z30 <br /> Fee Amount: �. (o Amount Pat (fib Payment Date '4 <br /> Payment Type , Invoice# Ch k# 83 Recelve By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> i <br /> I ' <br />