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_ SAN JOAQUIN ENVIRONMENTAL HEALTH�MZNT <br />SERVICE REQUEST <br />Type of Business or Property <br />B"gl ynterprises, Inc. <br />FACHM lD # <br />HomE or MmuNo ADDRESS <br />2370 Maggio Circle, Ste 4 <br />SERVICE REQUEST # <br />CITTodi tyTE ZIP <br />/Q dvre A7LW AZAA41ac�,Q <br />FA0003954 <br />04W-kt7 Ok - O1 ,e- jr4 5 <br />AAOoo� <br />County Government <br />AccEPTED BY: <br />ENPLOYEE g <br />OWNER I OPERATOR <br />Asswm m To: <br />cHEcx BpuriG AODREss <br />SJC Public Works ( Dan McCann- Fleet Manager) <br />If <br />FAcnmr NAuE <br />Date Service Completed (if already cornpietedj: <br />Cor ration Yard <br />P 1 E: <br />Fee Amount: / <br />Amount Paid 31 S , OZ <br />Paynierfi <br />Date cj 2_9 <br />Payment Type 1� " <br />Invoice # <br />SITE ADDRESS <br />1810 <br />cb-m* # Z ZkA9 :S <br />Hazelton v <br />Received By: W-r-- <br />Stoclzt <br />5 <br />StreetNnmber <br />ane <br />HOPE or MAIuNG ADDRESS Of Different from Site Address) <br />Sfieet Namber <br />sbydHarm <br />CITY <br />STATE Zip <br />PHONE #1 ET' <br />APN # <br />LAND 115E APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT LACATWM CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESsl <br />Joseph Bagley <br />B"gl ynterprises, Inc. <br />p� <br />LUy# 367-4800 <br />HomE or MmuNo ADDRESS <br />2370 Maggio Circle, Ste 4 <br />Fax# <br />(209 ) 367-5424 <br />CITTodi tyTE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorked agent of same, <br />acknowledge that all site and/or project specific ENMONMENTAL 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 0?&nance Codes, Standards, laws. <br />APPLICANT'S SIGNATURE: 7 DAT E: Oq /S 9I baa <br />PROPERTY/ Bos Nm owmm m[3 OPERAT MANAGoMm 0 OTHERAirrmmwwAGSNT ® Contractor <br />IfAPPLIcAAT is not the BILLING PARTY, proof of makorkAdon to sign is required title <br />AUTHORIZATION TO RELEASE I1V)N'ORMATION: When applicable, I, the owner or operator of the propertp aled at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environm <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HiEALTH DEPARTMENT as soon as it is available and at the t2w <br />provided to me or my eve. S rD <br />TYPE OF SERvicE REQUESTED: <br />SAJU 2008 <br />Co1IleENrs: 6�LXC G'Q9rmo4�/� ©9 � Gd <br />�EACTV I goNM6v],, Y <br />-Rovr .P��1S'E•t- �Z.o� <br />/Q dvre A7LW AZAA41ac�,Q <br />H DEPART TAC <br />_ S*YS73i-x d;;, Nr <br />04W-kt7 Ok - O1 ,e- jr4 5 <br />AAOoo� <br />AccEPTED BY: <br />ENPLOYEE g <br />DATE: <br />Asswm m To: <br />Etwi-orm iE <br />DATE: <br />Date Service Completed (if already cornpietedj: <br />I SElvlee CODE: <br />P 1 E: <br />Fee Amount: / <br />Amount Paid 31 S , OZ <br />Paynierfi <br />Date cj 2_9 <br />Payment Type 1� " <br />Invoice # <br />cb-m* # Z ZkA9 :S <br />Received By: W-r-- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />