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• SAN JOAQUOOUNTY ENVMOI*MENTAL HEALTJ*PA11TMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> San Joaquin County Owned � JC, ! <br /> OWNER i OPERATOR <br /> Dan McGann SJC Public Works Motor Pool Div. <br /> CHECK If BILLING ADDRESS <br /> FA%% tion Yard <br /> SITi fflRESS _ Hazelton Ave. Stockton: 95 0 <br /> BlUU Sheet Number rection Name c ode <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Sheet Number Stmt Name <br /> CITY STATE ZIP <br /> PHONE#1 0T r PN# LAND USE APPLICATION# <br /> l 209) 468-3106 <br /> PHONE#2 ET• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Joseph Bagley CHECK if BILLING ADDRE <br /> BUSINESS NAME PHONE# ' <br /> Bagley Enterprises, Inc. 209 367-4800 <br /> HOME or MAILING ADDRESS FAX# <br /> 2370 Maggio Circle (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 samq,r <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projecli <br /> or activity will be billed to me or my business as identified on this form. rc $ <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 /> �k <br /> COUNTY Ordinance Codes,Standards,STATE and F'DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 12/8/05 ;: <br /> PROPERTY I BUSINESS OWNER❑ OPERATO OTHER AUTHORIZED AGENT❑ <br /> 3: <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 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. PAYM E N T <br /> TYPE OF SERVICE REQUESTED: S' ,�£ U F HECEIVE D <br /> COMMENTS: DEC 9 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: (�L_I v/2-A- EMPLOYEE#: 2 DATE: 2 <br /> ASSIGNED TO: N L EMPLOYEE#: g7 L} DATE: j 2 l ps <br /> Date Service Completed (if already completed): SERVICE CODE: j P i E: <br /> Fee Amount: ff 2-7 y,c,E, Amount Paid v p Payment Date <br /> Payment Type ./ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />