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SAN JOAQU4VOUNTY ENVIRONMENTAL HEAL*EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE EST# <br /> County Owned Facility �Gd g <br /> C&=aya 1 <br /> s <br /> OWNER I OPERATOR <br /> S. J. County Public Works (Dan McCann - Fleet Manager) <br /> CHECK ifBILUNGAoDRE33 <br /> FAcILmNAME Sheriff's Operations Fueling Facility <br /> SITE ADDRESS 7000Michael Canlis Road French Camp 95231 <br /> Street Number Direct n 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 Exr. APN# LAND USE APPLICATION# <br /> c 1 1 43-:Go - <br /> PHONE#2 ExT• BOS DISTRICT LOCATION C DE <br /> ( ) <br /> CONTRACTOR 1 SERVICE REQUESTO <br /> R <br /> REQUESTOR <br /> Joseph Bagley CHECK if BILLING ADDREsAR <br /> eagleytiterprises, Inc. PH 367-4800 E <br /> HOME or MAILING/ADDRESS <br /> 2370 Maggio Cir. #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 d that the work to be performed will be done in accordance with all SAN JoAQunN <br /> COUNTY Ordinance Codes,Standards, (S d DERAL laws'I <br /> APPLICANT'S SIGNATURE: 6 DATE: <br /> PROPERTY/BUsmssowNER[3 or D -a OTHERAuTHORmD,A-mTE3 Contractor <br /> IfAPPrrcAm is not the BmLwGPARTY.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 availabe same time it is <br /> provided to me or my representative. E�r <br /> FRE <br /> TYPE OF SERVICE REQUESTED: <br /> SEA <br /> COMMENTS: 2006 <br /> SM`OAQi�IM ROIV COU <br /> HEgt D IIE <br /> PARMEW <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E Z b <br /> Fee Amount: Amount Paid a S, (� Paymeni Date <br /> Payment Type Invoice# Check# S Receied By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />