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SAN JOAQU*OUNTY EwI oNwNTAL HEAL*EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> County Owned Facility <br /> OWNER/OPERATOR <br /> S. J. County Public Works (Dan McCann - Fleet Manager) CHECK If BILLING ADDRESS <br /> FACILnY NAME Sheriff's Operations <br /> SITE ADDRESS <br /> 7000 Street Numb" Direction Michael Canls eat Named FrerI h Camp 95 clay <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE M EXT. APN# LAND USE APPLICATION# <br /> ( ) 3-0-So - QV- <br /> PHONE#2 ET- BOS DtsTRICT LOCAMON CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REouESTOR <br /> Joseph Bagley CHECK if BILLING ADDRES <br /> BZ ZfS Ifflterprises, Inc. PH�64 367-4800 <br /> HOME or MAILING ADDRESS FAX# <br /> 2370 Maggio Cir. A (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 ENviRomAENTAL 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,STATE and FEDERALlaws. <br /> APPLICANT'S SIGNATURE: DATE: 9/6/06 <br /> 1'rtOPERTY/Busu+t>Gss OwN>�It❑ OPERA /1V(nNA�R 0 OTHER AUTHORIZED AGENT Contractor <br /> IfAPPLxANT is not the BA,LwGPARTY 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: SE/'" <br /> 3q 1 ��'J <br /> N✓Oq <br /> H4"0141 N��Nry <br /> gRTMFN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE ODE: P/E. <br /> Fee Amount: Amount Paid S Payment Date <br /> Payment Type Invoice# Check# Recely d y: <br /> EHD 48-02-025 RM(Golden Rod) <br /> REVISED 11/17/2003 <br />