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SAN JOAQifOUNTY ENVIRONMENTAL HEALT1*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Hospital J 0 go <br /> OWNER l OPERATOR <br /> San Joaquin General Hospital CHECK If BILLING ADDRESS❑ <br /> F LITY N ME <br /> an Joaquin General Hospital <br /> SITE ADDRESS <br /> 500W Hospital Road French Camp 95231 <br /> Street Number n Name i od <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number SUM Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. rPN# LAND USE APPLICATION# <br /> ( 1 Ig 3 - C>So-t© <br /> PHONE#2 EXT. BOSDISTRICT, LOCATION CODE <br /> ( ) / <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Joseph Bagley CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Bagley Enterprises, Inc. 209 367-4800 <br /> HOME or MAILING ADDRESS FAX# <br /> 2370 Maggio Circle, A, (209 ) 367-5424 <br /> CITY Lodi <br /> STATE A ZIP 2 <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 ENVIRONMENTAL 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,Standards ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: fi�'- DATE: 4/2/09 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORiZEDAGENT 11 Project Manager <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property locate$4t+the r <br /> 14 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/ 'Issssment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the t* i <br /> provided to me or my representative. SAN;ZAJUq <br /> Qi <br /> TYPE OF SERVICE REQUESTED: UST Piping Repairer DE1Y <br /> T <br /> CO"ENTs: While conducting a scheduled tri-annual SB989 Secondary Containment Testing of <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 i6'ide of the piping sump to the outside of the <br /> sump. <br /> ACCEPTED BY: OC t V C— t EMPLOYEE#: ?� Zt DATE: t 3 0'9 <br /> ASSIGNED TO: Q EMPLOYEE M (2 DATE: L(- 3 q <br /> Date Service Completed (if alr ady completed): SERVICE CODE: et P i E:2.30;fo / <br /> Fee Amount: 3 1 S c*--d Amount Paid 3 S _ Payment Date 3 I O I <br /> Payment Type ✓ Invoice# Check# a�-�-7 2-- Received By: <br /> E H D 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />