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SAN JOAQUL' -JUNTY ENVIRONMENTAL HEALTH ,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> City Government <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> City of Lodi, Municipal Service Center <br /> FACILITY NAME <br /> Cor oration Yard <br /> SITE ADDRESS <br /> 1331 Street Number S,�n Ham Lane � Name Lodi ctty Z522 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number <br /> CITY STATE ZIP <br /> PHONE#'I APN# LAND USE APPLICATION# <br /> (209 ) 333-6706 <br /> PHONE#2 ExT• BOS DISTRICT LOCATto CODE <br /> ( ) 1--/ C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS® <br /> Joseph Bagley <br /> BUSINESS NAME PHONE# EXT. <br /> Bagley Enterprises, Inc. ( 2091367-4800 <br /> I{QAVIE pr MAIgLIgN'ADGp.REsis FAX <br /> )367-5424 <br /> Lj�U <br /> Maggio Circe Unit 4 <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 andlor project specific ENVIRONMENTAL HEALTH DEP:\RTMENT 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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: c DATE: 2122/Ila <br /> PROPIMTY/RUSIIvMowNER❑ OP OR/MANAGER ❑ OTI�rtAUlILORIZIDAGEFVTLI Contractor <br /> j IJAPPL/CANT is not the BILLNG PARTY,proof of authorization to sign is required Title <br /> AUT�ORIZATION TO RELEASE INFORMATION: When applicable,1,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 environmental/site 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: L'i r _I T <br /> COMMENTS: Application is made to comply with California Air REsources Board requirements <br /> for Gasoline Dispensing Facilities to upgrade Phase II Dispensing Systems with enhanced <br /> vapor recovery equipment. This facility will be upgraded using Franklin Fueling/Healy <br /> System as approved by CARB Executive Order VR-201-H. <br /> NOTE: ISD not required. <br /> EMPLOYEE#' DATE: �,3 <br /> ACCEPTED BY: C l V.A C)�Z t C <br /> ASSIGNED TO: C-•,4 C x�r 1-T- EMPLOYEE# (� ? L_ DATE: 6 C� <br /> Date Service Completed (if already completed): SERVICE CODE: CC. PIE: 23 i <br /> Fee Amount: Amount Paid 3�� Payment Date P3 o <br /> Payment Type Imroive# eck# yj�jI Received By: <br /> �F�c�3vFc� <br /> EH 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> , EB 2 3 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> YFAI TN nFPABTmFMT <br />