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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # sk <br /> SERVICE REQUEST # <br /> Schoolhio0L/'o C7f C( oo7y3 CS <br /> OWNER / OPERATOR <br /> Tracy Unified School District/Lisa Sawyer CHECK If BILLING ADDRESS <br /> FACILITY NAME Tracy Unified School District <br /> SITE ADDRESS 7pire <br /> Lowell Av Tracy 95376 <br /> 1975 Street Numbern I Street Name C ity Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> ( 209j 830-3230 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR .'�(i <br /> REQUESTOR Ann Marie or Joe CHECK if BILLING ADDRESS ; <br /> BUSINESS NAME PHONE # EXT. <br /> Bagley Enterprises , Inc 205 3674800 <br /> HOME or MAILING ADDRESS FAX # <br /> 2370 Maggio Cir #4 ( 209) 367-5424 <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 : DATE : 12, 1 <br /> PROPERTY / BUSINESS OWNER ❑ OPERA MAZAGER ❑ I CHER AUTHORIZED AGENT II Contractor/Desilnated Operator <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 assessor )� Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS protla Or <br /> my representative . R NT <br /> TYPE OF SERVICE REQUESTED : C �'� t <br /> COMMENTS : <br /> SA /V JOA ' 202 <br /> During the last monitor certification the overfill prevention valve testing failed . Replace failed �NI Qv/N C <br /> OPW 71 SO with like item . H�QLT PgRrM L y <br /> ACCEPTED BY: e L- e � EMPLOYEE #: DATE: 10 '24 <br /> ASSIGNED TO : � I IPre L�s to( EMPLOYEE M DATE: O .24 <br /> Date Service Completed ( if already completed) : SERVICE CODE : (�� � 2g PI E : 2 � � <br /> Fee Amount : C4 t� 0-0 Amount Pai �' Payment Date In l Z <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />