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SAN JOA# C0'UNTy7ENviRoNmENTAL HEALO- <br /> 1PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVIC U ST <br /> Hos ital t <br /> OWNER/OPERATOR <br /> San Joaquin General Hospital CHECK if BILLING ADDREss <br /> FAQ oaquin General Hospital <br /> SITE AoDREss <br /> 500 NumberSheet 6d Hospital Road French Camp 95232 <br /> c <br /> HOME Or MpuuuG ADDREss (if Different frown Site Address) <br /> MIRLHUMber <br /> CITY STATE zip <br /> PHONE#1 EKT. APN# LANQ Use AppucAnom <br /> ( 1 65®-1 <br /> p ExT. Sas DISTRICT, nON COaE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> EQUESTOR <br /> Joseph Bagley CHECK if BILuNG AMRESM <br /> E PHONE# EXT. <br /> Baglev Ente rises Inc. 209 367-4800 <br /> HOME2370 Maggio Circle, A,SS (209 ) 367-5424 <br /> STATE zip 2 <br /> CA <br /> 40 <br /> BILLING AC GE : I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONN ENTAL 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 Ordinance Codes,StandardsATE and FEDERAL laws. <br /> APPLICANT'S SIGNA DATE: 4/2/09 <br /> PRoPERTY/Buwqm o � opERATOR MANAGERO OTHER AUTH0RMEOAGFmJJ Project ager <br /> IfAPPLlCAAT is not the BILLttyGPARrr proofofauthorkadon to sign is rewired Title <br /> AUTHORIZATION T ASE N: When applicable,I,the owner or operator of the property loca 4tztlie-.t <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/ ' ssssment'° <br /> information to the SAN JOAQUIN COUNTY ENVIRONNENTAL HFALTH DFPARTWNT as soon as it is available and at <br /> provided to me or my representative, S tV�Uk <br /> TYPE of SERVICE ES : UST Piping RepaircowEw <br /> s: While conducting a scheduled tri-annual SB989 Secondary Containment Testing of 1' <br /> the UST system it was noted that a secondary containment pipe for the primary turbine <br /> as crack and testing failed. Preliminary investigation revealed that the cracked <br /> secondary piping extended from the idkde of the piping sump to the outside of the <br /> sump. <br /> ACC BY: C3 C i tr i E Lo a ( DATE: 1 <br /> AssnHEo To. <br /> - E Lo g: DATE: <br /> Date Service Completed (if airkady completed): SERVICE CODE: t p I E:,? <br /> Fee Amountif <br /> I J Payment Date <br /> Payment'Type ®/' Invoice check# a;;L--7 -7 Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />