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SAN JOAQUi...;OUNTY ENVIRONMENTAL REALTI,.,E PA RTM E NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Tracy Unified School District 7 <br /> OWNER/OPERATOR <br /> CHECK IT BILLING ADDRESS <br /> Tracy USD John Heerema 831-5051 <br /> F c0i00 Bus Garage <br /> SITE ADDRESS <br /> 1975 W Lowell Traqt 7� <br /> Street Number Duection Street Name e <br /> HOME or MAILING ADDRESS (1f Different from Site Address) <br /> SVeet Num4er SVeet Name <br /> CITY STATE ZIP <br /> �l�tt EXT. APN# LAND USE APPLICATION# <br /> I 09) 831-5051 <br /> PHONE#P En. BCS DISTRICT LOCATION CODE <br /> ( 209) 321-3923 (Cell) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joseph Bagley CHECK NBILLING ADDRES <br /> Bagley <br /> NAME ZOy# 367-4800 E� <br /> Be <br /> ag y terprises, Inc. <br /> HOME or MAILING ADDRESS FAX# <br /> 2370 Maggio Circle, Unit 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 <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 applica ltrol that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE and FiDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:11/11/05 <br /> PROPERTY/BUSDVE4.SOWNER❑ OPTo MANAGER OTHERAUTHORIZED AGEN ' Contractor <br /> If APPLICANT is not the Bl c 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaVsite 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. <br /> TYPE OF SERVICE REQUESTED: Remove and Replace Automatic Mechanical Line Detector PAYMENT <br /> COMMENTS: <br /> NOV 10 2005 <br /> SAN JOAQUIN COUNTI <br /> FIJVIRONMENTAL <br /> In n <br /> HEALTH DEPARTME <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> W20 <br /> Q� <br /> ASSIGNED TO: IN I.l EMPLOYEE#' / S 3 DATE: <br /> Date Service Completed N aImady pletad): SERVICE CODE: P,E: !Z <br /> Fee Amount: Z 7 , C/� Amount Paid lCiDPayment Date <br /> Payment Type Invoice# Check# \,9\ 3 a Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />