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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHjjDEPA TMENT <br /> SERVICE REQUEST I1 i��j - (�l -'� C G� nccC�loa <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> UST X)S3 �7 U <br /> OWNER / OPERATOR <br /> John Stagg CHECK If BILLING ADDRESS <br /> FACILITY NAME Digity Health - St . Joseph ' s Medical Center <br /> SITE ADDR''E1S//S,, � � � U tl' � ( kJ l 40f f) l �'t, t4' Stockton 95204 <br /> Ow Street Number Dlrecon Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> ( 209 ) 461 -6818 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( 209 ) 943-2000 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Terry Masters CHECK if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # ExT. <br /> ( 20 461 -6337 <br /> HOME Or MAILING ADDRESS 2535 Wigwam Dr FAX # 461 -6342 <br /> ( 209 ) <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 a p ' cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards ST TE and FEU RAL laws. <br /> APPLICANT' S SIGNATURE: ` (114,11 1, l DATES: 7/24/2019 <br /> PROPERTY / BUSINESS OWNER 1:1 OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Office Manager <br /> If APPLICANT is not the BILLING PARTY, proof of authoriZatio►l to sign is required Title <br /> I <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 IQs ssment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at theSQ t i ,it is <br /> jprovided to me or my representative . • I'e`� 11 <br /> TYPE OF SERVICE REQUESTED : Re. <br /> i <br /> COMMENTS: <br /> Esc o 940 �!9 <br /> gyp'4F�r���Y <br /> e� NT <br /> ACCEPTED BY: n V � EMPLOYEE #: /L��/ DATE: <br /> ASSIGNED TO : V �� �/ � EMPLOYEE #: l 5L DATE: 9 !� <br /> Date Service Completed (if already completed) : SERVICE CODE: / 9!� P / E:,>/ <br /> Fee Amount: y5� .ry Amount Paid Payment Date 8 9 <br /> Payment Type Invoice # Check # �ZZo'7g Rece ved By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />