Laserfiche WebLink
-R-n <br /> SH <br /> 121/23/201.14 17:06 20936740 BAGLEY ENTERPR a a PAGE 01/02 <br /> V CL <br /> WARTMENT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL JIBALTH DF D Er, 0 2 2 014 <br /> SIERNICE RIEQUEST <br /> Type of Susims ort' FACILITY IDAL HEALT <br /> �`i I <br /> San, Joaquin Country Sheriffs Ops OEPART ENT <br /> .owNm I OPr;RA'TOR CHECKff BILUNr <br /> SanDivision I Dan McCann-Mgr <br /> -FACmNAME Sheri""Is Ops <br /> SrrFADDRM : Michael Can�j7sBlvd pre <br /> ch Cap <br /> 9523 <br /> y zl c <br /> 1 <br /> HOME or MAILING ADDRE58 (if IDIfemnt"m Site Address) P 0 <br /> S,TC plect Services Division S Number V E D <br /> CqW.kt.,-CA 95201 <br /> ,D Llm AP <br /> EM APN* LAWD Un APFUCAnoN 0 DEC 2 3 2011 <br /> (209 1, 468-4645 7 1 Lo!a-nom 00VE <br /> BOS DWm'cT -INHI Wr if <br /> Pliowa EALTH <br /> CONTRACTOR SERvICE REQUFSTOR DEPAM6E <br /> R=EQUESTOR CHECK IIJ31�LM�ORV3513 <br /> Josepb 13agley <br /> Busy gsgslfthw Inc. 209367-4$00 <br /> le <br /> . <br /> le <br /> a;eyFAX# <br /> HOME or MAILING ApDRESS 20% 3b7-5424 <br /> 2370 Maggio Circle 44 <br /> STATE zip <br /> CnyLodi, CA 95240 <br /> EGENT; 1, the undersigned property or business owner,operator car siuthorii7zd agent of same, <br /> MONMENTAL HtALTH DEPARTKNT hOuTlY charges ILssociat)-ad With this project <br /> acknowledge that all site and/or project specific ENV <br /> or activity will be billed to me or my business as identified on this foray. <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 JOA,QUIN <br /> CouNTY Or4nance Ccmdes,Standardi,STATE and FEDERAL laws, <br /> OODA2Lr- <br /> APPLICANT'S SM'NATURE: UST Contractor <br /> P1toVvnW on//BUSINESS OWNTAM OTmm AurnOROrr)AGENT TWd <br /> if APPLICANT M mOt the=29�Ty proof of au&erkafion to s is required <br /> MQN TO IRM.EL : When applicable,1,the owner or operator of the property located at the <br /> above site addrem herby authorize the release of any and all results, geotechnica) data and/or environmental/site assessment <br /> information to the SAN IoAqUIN COUNTY ENVIRoNmEWAL HEALTH DEPARTS' as Son as it is avdiloble and at the samc time itis 0 <br /> provided to mo or my representative. olcl start weeder root system <br /> TYPE OF SERVICI!REQUEUM: Permit to <br /> COMM-NTS: <br /> Emergency repair to replace motor in -9-amP; needed to cold start der vee <br /> der <br /> AA <br /> root system -4--V A.. P4 <br /> DATE. <br /> ACCEP17D BY; EMPi-OY20'. <br /> EMPLOYIN#: DATE; <br /> AsmaNED TO: <br /> Data Service Completed (if already completed): k. Sawerp CGDE: PIE: <br /> I <br /> Fee Am rkt; Amount Paid <br /> Payment hate Received By: <br /> Payrron!t Type Invoice 0 <br /> SR FORM(Golftn RD(l) <br /> ErHD 49-02-025 <br /> REVISED 1111712003 <br />