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SAN JOAQU*OUNw ENVIRONMENTAL HEALTFOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />County Owned Facility <br />Line Leak Detector." <br />FACILITY ID # <br />L%� <br />SERVICE REQU ST # <br />(200 Y Ab -33 <br />OWNER / OPERATOR <br />S. J. County Public Works <br />(Dan McCann - Fleet Manager) <br />CHECK ifBILL1NGADDREss� <br />FACILITINAME Downtown Garage <br />PH2 <br />367-4800 <br />SITE ADDRESS 121S. <br />Street Number <br />Direction <br />San Joaquin St. <br />I Street Name <br />367-5424 <br />Stockton <br />city <br />95202 <br />Zio Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />PIE: <br />STATE Zip <br />PHONE #1 EXT. <br />'� 2 '7q, C pI <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 EXT. <br />( <br />Invoice # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REaUESTOR <br />Line Leak Detector." <br />CHECK if BILLING ADDRESM <br />Joseph Bagley <br />AUG 2 3 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Bag�eyiiterprises, Inc. <br />PH2 <br />367-4800 <br />HOME or MAILING ADDRESS <br />2370 Maggio Cir. #4 <br />ASSIGNED TO: l <br />FAX# <br />(209) <br />367-5424 <br />CITY Lodi <br />STATE CA <br />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 ENv>RONMENTAL 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 JoAQum <br />COUNTY Ordinance Codes, Standards, STATE and FE-DymAL laws. / <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINEss OWNER❑ OPER ATO Ab`ER-Q- , OTHER AUTHOREzED AGENT Li Contractor <br />If APPLICANT is not the Bff.LwG PARTI proof of autkorizadon 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. PAYMENT <br />pj—eNrf% irr-� <br />TYPE OF SERVICE REQUESTED: Replace "Mechanical <br />Line Leak Detector." <br />COMMENTS: <br />AUG 2 3 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: l <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: I q <br />PIE: <br />Fee Amount:Amount <br />Paid <br />'� 2 '7q, C pI <br />Payment <br />bate D � 0 <br />Payment Type V/ <br />Invoice # <br />Check # l ! —1 <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod <br />