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SAN JOAQUII10UNTY ENVIRONMENTAL HEALTHOARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fuel Dispensing Facility 1146 <br /> OWNER/OPERATOR <br /> Shawn Corporation CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Morada Chevron Fast-N-Easv #60 <br /> SITE ADDRESS <br /> 10878 Street Number I Di ion H' 99, Fro ggy Road St ton <br /> NG A 9 <br /> HOME or MAILING in Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 F-xT APN# <br /> LAND USE APPLICATION# <br /> (209 ) 931-6154 086-070-02 <br /> PHONE#2 EXT. BOS DISTRICT <br /> ( I LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> Joe Bagley-Bagley Enterprises, Inc. CHECK B BILLING ADDRESS® <br /> BUSINESS DAME PHONE# En. <br /> Bagley Enterprises, Inc _ <br /> 48110 <br /> H r MAILING ADDRES FAX# <br /> �1 Maggio Circe, Ste 4, (209 ) 367-5424 <br /> CITY Lodi STATE CA ZIP 95240 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards SPATE anFE ERAL laws. <br /> APPLICANT'S SIGNATURE: __ DAVE:: /, �`�p 7 <br /> PROPERTY/BUSINESS OWNER El OPERAT / NAGER ❑ OTHERAUTHORIZEDAGENTLJ Contractor <br /> If APPLICANT is not the Btwwa PARTT.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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: [Cr�cPC'r 2t'-E'il ),3'tiT I,YI�.t..� v1.`L'i` Wim <br /> Repieee Turbine Swag Sensor for Diesel Product. <br /> eE.eL , w:mW_ rz rrarr+€n fn*te <br /> sf/�.:.2 Cta'I�A oK <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> END 4M2-025 SR FORM(Goiden Rod) <br /> REVISED 11/17/2003 <br />