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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> (� <br /> OWNER I OPERATOR <br /> Randy Roehrich CHECK If BILLING ADDRESSO <br /> FACILITY NAME Lodi Memorial Hospital <br /> SITEADDRESS 975 S Fairmont St Lodi 95240 <br /> Street Number Direction I Street Name Cit ZI 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 /> ( ) 031061Y19 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT* <br /> 209 461 -6337 993 -4267 <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 Fation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar s, STA E and FEDERAL la <br /> APPLICANT'S SIGNATURE : 1 DATE: U <br /> PROP ERTY / B US IN ESS 0WNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® O ice Manager <br /> If APPLICANT is riot the BILLIArG 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& timMe"r ,it is <br /> provided to me or my representative. •TYPE OF SERVICE REQUESTED : //i j /2 ���i7 /�COMMENTS: SA <br /> FW�%/N C <br /> HFACTy FpgR )V <br /> ACCEPTED BY : /�/ ��� EMPLOYEE M 26 < U DATE: <br /> ASSIGNED TO : 2 AIL "IL EMPLOYEE 1) 03 DATE: r� <br /> Date Service Completed ( if already completed) : SERVICE CODE: 19 g P / E : Z3 D a <br /> Fee Amount: tl S (, Amount PaidTP 1600 Payment Date Iq 8 <br /> Payment Type Invoice # Ch k # 83 Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />