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SAN JOAQUOP NTY ENVIRONMENTAL HIPA 11 ARTMENT SERVICE REQUEST Type of Business Or Property FACS W# BUSINESS NAME SERVICE REQUEST # County Government -Fueling Site N-722 2370 Maggio Circle Ste 4, Lodi, CA 95240 00 �S OWNER / OPERATOR DATE: San Joaquin County, Dan McCann, Fleet Manager CHECK ifBILUNGADDRESS FAcIUTY NAME I DATE: ` Corporation Yard SMEE COM: SITE ADDRESS PIE: Z" Fee Amount: Tstocktqj69 3 k S. W Paymen 1810 s ---Hazelton Payment Type sb.et Check # 2 2 29 (� HOME or MAILING ADDRESS (If Different from Site Address) _. - Sbset Number Maggio Circle, Ste 4 CITY STATE zip Lodi PHONE #t EKT. APN # LAND USE APPLICATION # (209 ) 367-4800 PHONE R BOS DISTRICT LOCATION CODE (209 ) 329-0582 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Joseph Bagley - CHECK if Ba LING ADDRESS BUSINESS NAME PHONE# EXT' HOME or MAILING ADDRESS FAX# 2370 Maggio Circle Ste 4, Lodi, CA 95240 {L09 067-5424 CITY STATE zip BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVmONWNTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this appljcation and that the work to be performed will be done in accordance with all SAN JOAQUIN CouNTY Ordinance Codrs,-Sia ndwds, STA and FEDERAL laws. APPLICANT'S SIGNATURE;—,,DATE: 9/12/08 PROPERTY I Busuq 38 OWNER Q /�ORANAGIIt ' OTHER AuTHORTZEO AGENT Q IfAPPt is Atv't' is not t e B propf of authorhadon to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SEimcE REQUESTED: COMMENTS: SEP 1 2008 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE DATE: ASSIGNED TO: EMPLOYEE# I DATE: ` Date Service Completed (if already leted): SMEE COM: PIE: Z" Fee Amount: Amount Paid 3 k S. W Paymen I Date` 0 g Payment Type Invoice # Check # 2 2 29 (� Received By: EH 48-02-025 SR FORM (Golden Rod) REVISED 11/172003