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01/02/2015 12:58 2093675424 BAG-EY ENTERPRISES RECEVELL <br /> SAN JOAQUIN COUNTY ENMONMENTAL 19EALT19 DEPARTMNT JAN 0 2 2015 <br /> SERVICE REQUEST ENVIRONMENTAi <br /> TYPO of Business or Propany FAC(LitY 10 <br /> San Joaquin County Sheriffs c)ps <br /> OWMER I OMRATOR --------- <br /> San Joaquin Colmty Fleet Services Division/Dan McCann-Mgr <br /> FAGWYNAME <br /> Sheriffs ops <br /> ;SITE Aomss <br /> ichaeLLar <br /> ?000 N Michael Canlis Blvd French Ca 95231 <br /> HOME or MAI (Division <br /> I 211219M . I �p 20-0 <br /> UNG ADDRESS (if Z)ft t ftm 3116 Adftw) <br /> AJC Fleet Services Div' r <br /> Islon POBox 1810 <br /> 011tockton, CA 95201 STAIR ZIP <br /> PHOW#1 Ott• <br /> APNO LAND USE APPLICATION <br /> (209. k 468-4645 <br /> EXT. 009 DBMICT E AMN IGOM <br /> REQUESTOR 'CONTRACTOR SERVICE REQUESMR <br /> Joseph Bagley <br /> Suss <br /> aLFrAME <br /> ey EllteMrSCS Inc. <br /> f 209)367-4gOQ <br /> Hwn orWu Apo Rm FAX <br /> 2370 TMjo Orcle#4 1 <br /> 2Q9}367-5424 <br /> CITY Lodi, CA 95240 STAIA zP <br /> 1, the undersigned property or businew owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvmoNMENTAL HEALTH DEPARTMENT hourly charges associated with this pro'cot <br /> or activity will be billed to me or my business as identiflod on this form. <br /> I also certify that I have prepared this application and that the work to be pmformed will be done in accordance with all SAN JOAQUIN <br /> COuNry ordiwnce Codes,%ndar&.STATEpd PuDFRAL laws, <br /> I <br /> APPLICANT'S SIGNATURE:-- ~,A.) 404L,1- DATE: 7/,?/4;l0/ <br /> BUMLIS OWNWE3 tar/MANA( OMER AuTnoRlzzb AGvu 11 UST Contractor <br /> 1f A"LnAT is nOf the 814AV2A=PrOOf of authorizadon to dgn is requiroW -- Thle <br /> 2RMAMN—3M When applicable,1,the owner or operator of the property located at the <br /> above site address, hereby autWZO the release of any and all results, geotechnical data and/or environmental/site assessment <br /> infbrmatiOfl to the SAN.IOAQEjTN COUNTY ENMONMENTAL 14EALTH DEPARTMT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> 'rYK oF-SmvIcE Ft-QUMED: Permit to Cold start veeder root system <br /> comWE: Emergency repair to replace motor In pump; needed to CF!d -sFart Veed r <br /> root system. Includes the replacement of a Veeder Root interstitial <br /> Sensor, p/n 794390-409. Sensor installed 12/30/14 . <br /> 12/31/14: Performed cold start to veeder root system <br /> Acm,mm by: RM #: DATE.' <br /> ASSioNev TO: EMPLOYEE!9: DAT <br /> Date Service Completed pf*In mdyc0nW1gftd): 73-mm 0M. P1 <br /> Fee Amount -- Amount Paid Asymnt Date <br /> Payrnent Type invoice 0 Check# Received 13y; <br /> RHD 48-02-023 <br /> REVISED 1111712003 SR FORM(Golden Rod) <br />