COMPLIANCE INFO_2024 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # City fueling facility S R a 4 (25m 3013 OWNER / OPERATOR City of Lodi CHECK if BILLINGADDRESSE] FACILITY NAME City of Lodi SITE ADDRESS 1331S Ham Lane Lodi FZip 5242 Street Number Direction Street Name Cit Code HOME or MAILING ADDRESS ( If Different from Site Address) 221 W Pine St Street Number Street Name CITY STATE ZIP Lodi CA 95240 PHONE #1 EXT APN # LAND USE APPLICATION # (los ) 333 -6800 PHONE #2 EXT, BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Joseph Bagley CHECK if BILLING ADDRESS x BUSINESS NAME PHONE # EXT. Bagley Enterprises , Inc 209 -367-4800 HOME or MAILING ADDRESS FAX # 2370 Maggio Cir #4 ( ) CITY Lodi STATE CA ZIP 95240 BILLING ACKNOWLEDGEMENT : I , the undersigned property or business owner, operator or authorized agent of same , acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form . I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws . AT, FF . FC A NT ' ,2 IrIIA7rJRE9 �4�eANAZ2 � DATE : 6/27/24PROPERTY / BUSINESS OIVNER ❑ OPE TOR / OTHER AUTHORIZED AGENT ❑ _Contractor If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property loca Rd at the above site address , hereby authorize the release of any and all results , geotechnical data and/or env ironmental/siteis I�iel�atn information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sartl�l�i tie. ITJ �A it provided to me or my representative . (, � VcYD TYPE OF SERVICE REQUESTED : Uv T C COMMENTS : 111VJO Zy ElvVl 4 Qtlllv A CC Removing existing dispenser and installing new Helix dispenser. Anchor dispenser. Reconnect existing wiring , re-install existing hoses �aZ6 At / nozzles . Re-install sensors . Start up testing and purge . Calibrate dispenser, NT ACCEPTED BY : SIEMPLOYEE # : DATE : 7 ASSIGNED TO : JV EMPLOYEE # : DATE : Date Service Completed ( if already Completed ) : SERVICE CODE : r P I E : �0 Fee Amount: �'zi Amount Paid , Payment ate 0Z) Payment Type Invoice # I Check # 193 77Receive By : " EFID 48-02-025 ' Z3 / e SR FORM (Golden Rod) REVISED 11 /17/2003