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SAN JOAQi*COUNTY ENVIRONMENTAL REAL*EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> County Owned Facility S kov Ly Z&('�" <br /> OWNER I OPERATOR <br /> S. J. County Public Works (Dan McCann - Fleet Manager) <br /> CHECKffBILLiNGADDRESS <br /> FACILITY NAME Corp. Yard <br /> SITE ADDRESS <br /> E 1 Hazelton Ave. Stockton 95202 <br /> 1810 stmt Number DIreation Street Name C 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 /> PHONE#Z EXT. SOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Joseph Bagley CHECK if BILLING ADDREs <br /> B agusNAnterprises, Inc. PHV 367-4800 E>R <br /> HOME or MAILING ADDRESS F X# 367-5424 <br /> 2370 Maggio Cir. #4 ( ) <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 DEPARTmENI•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,Standar and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 06/i?m " <br /> PROPERTY/BUSINESS OWNER❑ O TOR/MANAGER OTHER AUTHO1uzED AGENT Contractor <br /> If APPLrcANT is not the B&LwG PARTE proof of authoripWon 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 e time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> G <br /> ��'� =' - ��' - �JC7.3G. • SPN °NMENjPENS <br /> oA' EPPa�M <br /> ACCEPTED BY: L /LCI �� EMPLOYEE M c, Z DATE: c) 2-7( � <br /> ASSIGNED TO: r L S EMPLOYEE#: -(L DATE: 6 L�r t)r- <br /> Date Service Completed (if already completed): SERVICE CODE: O P/E:,�-3.G(Z- <br /> Fee Amount: w1 C Amount Paid y�� l7 Payment Date <br /> Payment Type Lam" Invoice# Check# (01 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />