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8' <br /> oRECEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OCT 10 2016 <br /> SERVICE REQUEST q <br /> Type of Business or Property FACILITY ID# EN V' 96 WILL H LTH <br /> Gas Station I DEPARTMENT <br /> OWNER OPERATOR CHECKNBILLINGADDRESS <br /> Randy <br /> FACILITY NAME Lodi Memorial Hospital <br /> SITE ADDRESS 975 S Fairmont Lodi 95240 <br /> Street Number Direction =Street <br /> a Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) Street Name <br /> CITY STATE ZIP <br /> PHONE#1 <br /> EXT, APN# LAND USE APPLICATION# <br /> ( 209 ) 339-7667 <br /> PHONE#Z EXT• SOS DISTRICT LOCATION CODE <br /> ) Q <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECK ifBILUNGADDRESS <br /> PHONE# <br /> BUSINESS NAME Elite IV Contractors 209 461-6337 <br /> HOME:or MAILING ADDRESS FAX# <br /> 2535 Wigwam Dr ( 209 ) 461-6342 <br /> CITE' 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATEandFEDERAL laws.J,, <br /> APPLICANT'$SIGNATURE: 69, DATE: 10/7/2016 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 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,1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and ail 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 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 i <br /> COMMENTS: <br /> i RFCFir <br /> t I <br /> �i�Ro� Fib <br /> OEp� M5� <br /> ACCEPTED BY: EMPLOYEE#: DATE: !� c3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P i <br /> Fee Amount: Amount Pa Payment Date <br /> Payment Type l Invoice# z. <br /> Che # � Recei d By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />