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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> County Facility FA00(o z5q z5% < E S� 0 0 <br /> OWNER I OPERATOR <br /> San Joaquin County Fleet Svc —Public Works CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> San Joaquin County Fleet Svc - CorD Yard <br /> SITE ADDRESS 1810 E Hazelton Ave Stockton 95205 <br /> Street Number Dlrectlon Street Name City ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 1810 Street Number S eet Name <br /> CITY STATE ZIP <br /> Stockton CA 95201 <br /> PHONE #1ExT APN # LAND USE APPLICATION # <br /> t 209) 4684645 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> t I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Joseph Bagley CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE # ExT. <br /> Bagley Enterprises, Inc 204 367.4800 <br /> HOME or MAILING ADDRESS FAX # <br /> 2370 Man 'io 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 1 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 SIGNATI4k§ : /�.L� DATE : <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® UST 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 /> t0 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 : 3p"&Weket 1nsple9W""4- (� ��' Al, <br /> COMMENTS: NOV <br /> During the last monitor certification the UDC's failed testing; will replace UDC's N l 6 2012 <br /> 3A NVI aQUIN C <br /> HEgLTH pEpq r ENTY <br /> ACCEPTED BY: EMPLOYEE M. DATE: <br /> ASSIGNED TO: �' Q� EMPLOYEE #: DATE: /// ("'o /Z L <br /> Date Service Completed (if already completed) : SERVICECODE : 1 i 'Zqo PIE: 1DC78 <br /> Fee Amount: 1 f c° Amount P c���� b� Payment Date <br /> Payment Type Invoice # Check # �(�� Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />