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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> City Corp Yard r/ Q (� 6 ' ��(ZOD 6 � I —] 5 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> City of Lodi <br /> FACILITY NAME City of Lodi <br /> SITEADDRESS 1331 S Ham Lane o i <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'1 ExT. APN# LAND USE APPLICATION# <br /> ( I b3I - - gz--) <br /> PHONE#2 <br /> EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR �[ <br /> REQUESTOR Joseph Bagley CHECK if BILLING ADDRESSO <br /> ONEE <br /> BUSINESS NAME Bagley Enterprises, Inc. PHO 367-4800 EXT. <br /> HOME orMAIUNG ADDRESS 2370 Maggio Cir #4 Fax# <br /> ( 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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT)and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> I' Contractor <br /> PROPERTY/BUSINESS OWNER❑ OPLIRATOR/MANAGER I OTHER AUTHORIZED AGENT <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 propeWMENT <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentREORYIM <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tarae time It is <br /> provided to me or my representative. U T d 1 2013 <br /> TYPE OF SERVICE REQUESTED: S X14' SAN JOAQUIN COU TY <br /> COMMENTS: HEALTH DEPARTMFf NIT <br /> 1. Upon annual inspection found spill container failed to contain a minimum capacity o <br /> 5 gallons. Drain valve on order. <br /> 2. Overfill prevention audible alarm failed. <br /> Emergency repair to remove and replace overfill audible alarm, p/n VR790091-001. <br /> ACCEPTED BY: &q EMPLOYEE#: 2L 7C) DATE: 16 <br /> ASSIGNED TO: EMPLOYEE#: /4 Z Z DATE: > <br /> ti L, v <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P I E: Z 2 p (� <br /> Fee Amount: 3 7 Amount Paid 3�C Payment Date <br /> Payment Type Invoice# Check# ���j�� Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />