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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Public Works FA0003961 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> City of Lodi <br /> FACILITY NAME <br /> Lodi Muni Service Center <br /> SITE ADDRESS 1331 S Ham Ln Lodi 95242 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P O Box 3006 Street Number Street Name <br /> CITY STATE ZIP <br /> Lodi CA 95241 <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 209 333 - 6800 03104050 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Bagley CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE # EXT . <br /> Bagley Enterprises Inc 209 3674800 <br /> HOME or MAILING ADDRESS FAX # <br /> 2370 Maggio Cir #4 ( 2q9 327 - 5424 <br /> CITY Lodi STATE CA 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 ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form . <br /> 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 : ( t DATE : DG '0 9; 1; 'e136 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER OTHER AUTHORIZED AGENT 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me Or <br /> my representative . ^ <br /> TYPE OF SERVICE REQUESTED : Sm"rN <br /> Yb <br /> COMMENTS : Aeisi6 <br /> Replace the 87 and 91 spill containers (direct bury buckets) psr� OP 4TU3f' s w /0 �J� <br /> lx, ro Rt.Pv�� V at'�v� i3uC17� <br /> S'4 IV J N 2020 <br /> NFA TNRAt <br /> ON ! COUNT <br /> ACCEPTED BY : ��� f /�A EMPLOYEE #: DATE: / r <br /> ASSIGNED TO : ( 7 `� EMPLOYEE #: DATE : <br /> tl <br /> Date Service Completed ( if already completed) : SERVICE CODE : �i P ! <br /> E <br /> Fee Amount: � C� Amount Pai �� O Payment Date 1p � � <br /> Payment Type Invoice # Check # 2�O Receiv d By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/17/08 <br />