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SAN JOAQU*OUNTY ENVIRONMENTAL HEALT*PARTMENT <br />SERVICE REQUEST i 0 _U <br />Type of Business or Property <br />CHECKffBILLINGADDRESS 121 <br />FACILITY ID # <br />SERVICE REQUEST # <br />SONE # Exr. <br />agey Inc. <br />v 40 3 7 o'7 <br />j <br />-7 <br />County Owned <br />FAX # <br />1209 )367-5424 <br />CITYLodi <br />OWNER / OPERATOR <br />ASSIGNED TO: 1. <br />CHECKHBILUNGADDRESS <br />Facilities Management 212 <br />N San Joaquin St., Stockton 95202 <br />FACILITY NAME <br />P I E: 23 2 <br />Fee Amount: 2J57 <br />San Joaquin Jail Facilit <br />Payment Date C l (o( 0 <br />SITE ADDRESS <br />Invoice # <br />Check # a I (3 <br />Received By: <br />7000 <br />N <br />Michael N. Canlis Blvd <br />French <br />Camp <br />95231 <br />Street Number <br />D1raction <br />Street Name <br />C <br />Mp Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE <br />zip <br />PHONE #1 Exr. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z Exr. <br />BOS DISTRICT <br />( LOCATION COD <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Bagley Enterprises, Inc. <br />CHECKffBILLINGADDRESS 121 <br />BU INE NA <br />enterprises, <br />NOV <br />3 6 2006 <br />SONE # Exr. <br />agey Inc. <br />_ <br />HOME or MAILING ADDRESS <br />2370 Maggio Circle, Ste 4 <br />FAX # <br />1209 )367-5424 <br />CITYLodi <br />STATE CA ZIP 5 240 <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 JOAQUIN <br />COUNTY Ordinance Codes, Standar and EDERAL laws. <br />APPLICANT'S SIGNATURE: fdtl�DATE: 11/9/06 <br />PROPERTY/ BUSINESS OWNER 13 OPERA /MANAGER OTHER AUTHORIZED AGENT -'M Contractor <br />If APPLICANT is 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 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: S f C� <br />i L c' i ; r r- <br />COMMENTS: <br />NOV <br />3 6 2006 <br />SAN JOAQJIN CCUN,, y <br />ENVIP,,QNN;EIVTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />L <br />DATE: I l 6 <br />ASSIGNED TO: 1. <br />EMPLOYEE #: %t � 3 <br />DATE: <br />Date Service Completed (if already c pleted): <br />SERVICE CODE: <br />P I E: 23 2 <br />Fee Amount: 2J57 <br />Amount Paid <br />Payment Date C l (o( 0 <br />Payment Type ✓ <br />Invoice # <br />Check # a I (3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />