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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or PropertyI � � FA��Y ID # Srig �EQ EST # County Facility f D + f) "q OWNER / OPERATOR San Joaquin County Fleet Svc -- Public Works CHECK if BILLING ADDRESS FACILITY NAME San Joaquin County Fleet Svc - Sheriffs Ops # 1 SITE ADDRESS 7000 Michael Canlis Blvd French Camp Street Number Direction I Street Name Citv Zi Code HOME or MAILING ADDRESS (if Different from Site Address) P . O . Box 1810 Street Number Street Name CITY STATE ZIP Stockton CA 95201 1441 D PHONE #1 EXT . APN # LAND USE APPLICATION # ( 209 ) 4684645 SAN JOAQUIPJ col ,111r, PHONE #2 EXT • BOS DISTRICT �LS�TITfi�9 IV iA ( ) RTME T CONTRACTOR / SERVICE REQUESTOR REQUESTOR Joseph Bagley CHECK if BILLING ADDRESS BUSINESS NAME Bagley Enterprises , Inc PHONE # EXT . 20 3674800 HOME or MAILING ADDRESS FAX # 2370 Maggio Cir #4 ( 209) 367-5424 CITY Lodi STATE CA ZIP 95240 BILLING ACKNOWLEDGEMENT : I , the undersigned property or business owner, operator or authorized agent of same , acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form . 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 COUNTY Ordinance Codes, Standards, STATE' and FEDERAL laws . q APPLICANT ' S SIGNATURE : t`' DATE : ff PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER V OTHER AUTHORIZED AGENT ® UST Contractor If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me or my representative . TYPE OF SERVICE REQUESTED : Spill Bucket replacement COMMENTS : yt QAJL• A N(v vt M�f �,s�j�ir+L C 12 j Z LA��D� �}z4 p JTZ. L i} �✓Q U A4mx� o, PoOS A7kaoja two i tz S ACCEPTED BY : ;� , I / / ^ _ EMPLOYEE M �6 Q DATE : ASSIGNED TO : i VIEEMPLOYEE M Z DATE : Date Service Completed ( if already completed ) : SERVICE CODE : R �/ PIF : Fee Amount : Amount Paid L fS� v� Payment Date Payment Type /*Y!? Invoice # Check # Z3 �� Received By : EHD 48-02-025 ORIGINAL 07/17/08