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SAN JO.&IN(4pNTY ENVIRONMENTAL HE4&HH TMENT <br /> SERVILE REQUEST <br /> • Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> County Government T- FA0003954 1�;)e©0,5-&�+ ' <br /> OWNER I OPERATOR <br /> SJC Public Works (Dan McCann - Fleet Manager) CHECK rt B�LINc ADDREss <br /> FAcluw NAME <br /> CorDoration Yard <br /> S 1810 Ew <br /> 1 Hazelton v Stockt 5 <br /> HOME or MAKING ADDRESS (if Dtwemnt from site Address) <br /> S 3 G P 1ABL-Tc- W 4R WS FI�r.a ,7 ' tKw Sheet Number Street Name <br /> CITY STATE A I•�^ ZIP <br /> s`i�CSL:i7kV C_ <br /> PHONE#t APN# LAND USE APPLICATION# <br /> (20,1) 3164, 1 iS- 1 SQ t32 <br /> PHONEN ERr. BOS DISTRICT LOCA T rrCODE <br /> ( ) f <br /> CONTRACTOR i SERVICE REQUESTOR <br /> REQUESTOR <br /> Joseph Bagley P CHEcrc if Ba LRIG ADDREss <br /> Bu'ra.gley terprises, Inc. LUy# 367-4800 <br /> HOINE or MAiumG ADDRESS Fax# <br /> 2370 Maggio Circle, Ste 4 (209 ) 367-5424 <br /> e ,odi ►TE ZIP <br /> -40 <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 ENvIRo)aAENTAL HEALTH DEPARTMEmr 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 m accordance with all SAN JoAQuna <br /> COUNTY Ot&nwwe Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ?'' DATE: 3/11/09 <br /> PROPERTY/BrrmqEss owr mO on.T c m 0 0mmAvraox>zEDAGmT® Contractor <br /> IfAPPLICANT is not the Blum PAHI7 proofofenIfierkAdon to sign is regarred Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property ted at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/ t <br /> information to the SAN JOAQUIN COUNTY ENviRoNmENTAL HEALTH DEPARTMENT as soon as it is available and at the y` <br /> provided to me or my representative. 44 �Q <br /> TYPE OF SERYIcE ReauevrED: ,7 E � ��_ SAN ZO <br /> c0111MEM RE: CCR 2638(a), the Annual Line Leak �eteecttor� for 87 product tangy N <br /> VCO <br /> 3 gph leak test during EHD inspection 0L" ,g 0'. rt~n-n- rna7�2c% <br /> C:. laI LFa1G a€AV-61'e¢..t SPS-( ci iST; MFIyT <br /> AP PLazwrko-� y, hep£ -ro ¢£A,.-E r-su Lry L.10 f- L F*te O f~;TExao2 LD m-" <br /> New T (" P/13 qqt "-2-OtV \eltnT, <br /> f �SP�t Si�� <br /> ACCEPTED BY: C) C i t , ✓�4 EMPLOYEE#: 2, L/ DATE: 3 ( z (U z <br /> AswGNEDTo: LAjU raj EMPLOYEE a �1 L, DATE: '3 <br /> Date Service Completed (if aheady compietedy SBmm Dow. $r P I E: <br /> Fee Amount: 1 j _5- 1,() Amount Paid 3 I s — Payment Date 3 1 <br /> Payment Type Lam" Invoice# Check# Z 2 Received By: <br /> EHD 48-02-M _`J �� SR FORUM(Golden Rod) <br /> REVISED 11/172003 <br />