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SAN JOAQUIiOUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fuel Dispensing Facility 1146 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Shawn Corporation <br /> FACILITY NAME <br /> Morada Chevron Fast-N-Easy #60 <br /> SITE ADDRESS �T <br /> 10878 Street Number DIrAioo I HWY 99, Fro &&Road Std, ton 9J W, <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SVaat Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209 1 931-6154 086-070-02 <br /> PHONE#Z ExT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Joe Bagley-Bagley Enterprises, Inc. CHECKRBILLING ADDRESS <br /> BUSINESS NAME PHONE# EZT. <br /> Baglev Enterprises, Inc - <br /> HQMFi8rMAILING Maaggio Circle Ste 4 FAX 20 <br /> LLSS Maggio , , (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 application and that the work to be perfo med will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STATE and\E ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> r `)7 <br /> PROPERTY/BUSINESSOWNER❑ OPERAT / NAGER ❑ OTHERAUTHORMD AGENT la Contractor <br /> IjAPPL1caNrisnottheBrzttyGPaxrrproof Ofauthorization tosign isrequired Title PAYMENT <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the propert}Ree@9(itf/Et0 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asses�jm��jj��(}}L}p�9 <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the t#u8 J03 <br /> provided to me or my representative. CA a InAqVJN COUWy <br /> TYPE OF SERVICE REQUESTED: HEALTH DEF AR ENT <br /> COMMENTS: <br /> Replace Turbine Sump Sensor for Diesel Product. 0^/ i/1Z/O lq_C <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: vo EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: 5 r" Amount Paid 13 Is-, 0"0 Payment Date L 3 <br /> Payment Type ✓ Invoice# Check# 9,;2fgyp Received By: 2 C <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />