Laserfiche WebLink
SAN JOAQURCOUNTY ENVIRONMENTAL HEALTH RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> San Joaquin County Sheriffs Ops � 5Ibm OM-C, <br /> OWNER/OPERATOR <br /> San Joaquin County Fleet Services Division/Dan McCann-Mgr CHECK if BILLING ADDREss <br /> FACILITY NAME <br /> Sheriffs Ops <br /> SITE ADDRESS 7000 N Michael Canlis Blvd French Ca p 7.9?cI2, <br /> 31 <br /> Street Number Direction Street Name C' <br /> HOME or MAILING ADDRESS (If Different from Site Address) P O BOX 1810 <br /> SJC Fleet Services Division Street Number Street Name <br /> CITY TATE zip <br /> Stockton, CA 95201 <br /> PHONEY E r. APN# „ LAND USE APPLICATION# <br /> (209 ) 468-4645 I(1 3 <br /> PHONE#2 EXT• BOS DISTRICT ( LOCATION CODE <br /> I 1 D <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Joseph Bagley CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ems' <br /> Bagley Enterprises, Inc. 209 367-4800 <br /> HOME or MAILING ADDRESS FAX# <br /> 2370 Maggio Circle#4 ( 209) 367-5424 <br /> CITY Lodi, CA 95240 STATE zip <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �Zi��,.� y ?�;% DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT EX UST Contractor <br /> If APPLICANTis not the BILLING PARTY,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 enviqM <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabl � –tyme it is <br /> provided to me or my representative. W <br /> TYPE OF SERVICE REQUESTED: Permit to cold start veeder root system DEC <br /> COMMENTS: SAN JOAQUIN COUNTY <br /> Emergency repair to replace motor in pump; needed to cold" Wi&Afl A NT <br /> root system <br /> ACCEPTED BY: tre�= EMPLOYEE#: DATE: (� l <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed)l SERVICE CODE: ' 1 3 P 1 E: <br /> Fee Amount: t2 Amount PaidB — Payment Date <br /> Payment Type Invoice# Check# O Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />