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SAN JOAOUIN GOWNTY FNVIRONMENTAI . HI- AI .T H DEPARTMENT <br /> SERVICE. REQUEST <br /> Type of Business or Pro erty FACILITY ID # SERVICE REQUEST # <br /> 4S(2, WigI2AV 4�=A <br /> OWNER / OPERATOR <br /> Randy C1iECIC If BILLING ADDRESS <br /> FACILITY NAME Lodi Memorial Hospital <br /> SITE ADDRESS 975 S Fairmont Ave Lodi 95240 <br /> Street Number Directlon 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 ) 339-7667 0 0 74�00 '3 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> 11 6DI4 11 02 <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Megan Mitchell CHECI< if BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # ExT. <br /> 209 61 -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 or <br /> 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 , STATE and FEDERAL laws . <br /> APPLICANT' S SIGNATURE : ,! <br /> DATE ; J � 'l�� l ] <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / 14NAGER ❑ OTHER AUTHORIZED AGENT 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 , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment � ation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time It IS prov dIffft <br /> my representative . <br /> ��e/1�- <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: 00 <br /> �aLryo�qCO� <br /> r <br /> ACCEPTED BY : l� EMPLOYEE #: DATE: Ze /1 <br /> ASSIGNED TO : �� EMPLOYEE #: � DATE: O T ` <br /> Date Service Completed ( if already completed SERVICE CODE : PIE: <br /> Fee Amount : t�� oU Amount PaiPayment Date ]Q ] ] <br /> Payment Typei� Invoice # Check # 6r ZZ Received By: <br /> EHD 48-02-025 SR FORM ( Golden Rod) <br /> 07/17/08 <br />