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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 (fwu}►tGzt�t_ S f� <br /> OWNER I OPERATOR <br /> City of Lodi CHECK If BILLINGADDRr:ss <br /> FACILITY NAME City of Lodi <br /> SITE ADDRESS 1331 S Ham Lane Locil <br /> Street Number DI Ii Street Name city ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Stroet Name <br /> CITY STATE LP <br /> PHONE 81 Err. APN S LAND USE APPLICATION 0 <br /> ( ) <br /> PHONE 92 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Bagley Joseph P g Y CHECK If BILLING ADDRESS <br /> BUSINESS NAME Bagley Enterprises, Inc. PHOM EXT. <br /> 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: DATE: ///a 9, <br /> PROPERTY/BUSINESS OWNER❑ 064TOR/MANAGER ❑ OTHERAUTHORYLEDAGENT L7 Contractor <br /> IfAPPIJCANT is not the BILLING PARTY.proof of authorization to sign is required Titre <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 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: S <br /> COMMENTS: <br /> During SB989 testing unable to test UDC due to torn Secondary Test Boot on the Diesel Secondary <br /> Pipe. Will replace test boot. <br /> Will repair breached electrical conduit penetration on south wall for the cathodic protection wiring <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (it already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type invoice# Check 9 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />