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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SSERVICE REQUEST # <br /> f <br /> County Fleet Vd0 <br /> �� 3� <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS <br /> San Joaquin County Sheriffs Ops #1 <br /> FACILITY NAME San Joaquin County Sheriffs Ops #1 <br /> SITE ADDRESS N Michael Canlis Blvd French Camp 95231 <br /> 7000 Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) S Wilson Wy <br /> 444 Street Number Street Name <br /> CITY StOCkOn STATE ZIP <br /> ca 95205 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 209 468-3099 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Ann Marie or Joe CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Ba Ie Enterprises , Inc <br /> 20 367-4800 <br /> HOME or MAILING ADDRESS FAX # <br /> 2370 Maggio Cir #4 ( 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 or <br /> activity will be billed to me or my business as identified on this form , <br /> 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 : r DATE : G7 ,3d ) 21 <br /> PROPERTY / BUSINESS OWNER ❑ OPERA GER IfTHER AUTHORIZED AGENT Contractor/Desii?nated Operator <br /> If APPLICANT IS not the BILLING PART .Yproof 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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> 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 <br /> my representative. � 7- 1 <br /> TYPE OF SERVICE REQUESTED : ( I ulup-�qbg-- �E / Y T <br /> COMMENTS : D <br /> During the last monitor certification the overfill prevention valve testing failed . Replace failed SAN ocr ?421 <br /> OPW 71 SO with like item . ENVO/ AQU/N CONFA � TyQE qNL rY <br /> N <br /> ACCEPTED BY : EMPLOYEE #: DATE: l/ 0 <br /> ASSIGNED TO : XY EMPLOYEE #: DATE: <br /> Date Service Completed ( if already completed) : SERVICE CODE : ( �/ 2� � P I E ; 2 <br /> Fee Amount : z/ oD Amount Paicvp <br /> Payment Date <br /> Payment Type Invoice # Check # Sv Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />