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SAN JOAQI --OUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> City Corp Yard li�'LLr,tC.LPrk�_ 5tr• r_ ^ C'rY/ ��! I C- 'J—' <br /> hj l t I <br /> OWNER/OPERATOR <br /> City of Lodi CHECK if BILLINGADDRESSE] <br /> FACILITY NAME City of Lodi <br /> SITE ADDRESS 13 31S Ham Lane o i <br /> Street Number Direction Street Name city 77Z5.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 /> PHONE#2 EXT. BOS DISTRICT I LOCATION CODE <br /> ii 1 ) , ` 1 11 "), <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Joseph Bagley P 9 y CHECK If BILLING ADDRESS <br /> BUSINESS NAME Bagley Enterprises, Inc. PHO�FD#9 EXT. <br /> L 367-4800 <br /> HOME or MAILING 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: \ f�T DATE: 1"A2 <br /> PROPERTY/BUSINESS OWNER❑ TOR/MANAGER ❑ OTHER AUTHORIZED AGENT Contractor <br /> IfAPPLICANT 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 property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asA'sst'ment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sam ttfif <br /> provided to me or my representative. �FCFI T <br /> TYPE OF SERVICE REQUESTED: C do <br /> V Z <br /> COMMENTS: H F'I'1 Aw/A, <br /> 'A-44N CA'MFCOu <br /> 4,7 <br /> During SB989 testing unable to test UDC due to torn Secondary Test Boot on the Diesel SecondaAR <br /> Pipe. Will replace test boot. <br /> Will repair breached electrical conduit penetration on south wall for the cathodic protection wiring <br /> ACCEPTED BY: ` �,J f:0 EMPLOYEE#: DATE: <br /> ASSIGNED TO: '�2 I 0EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: <� <br /> Fee Amount: G� , �T, Amount Paid Ll <br /> 4--Z Payment Date <br /> Payment Type (T kL_ Invoice# Check# 31SZ2— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />