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SAN JOAQUIJ*OUNTY ENVIRONMENTAL HEALTHOPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Commerical 1=A 00000 g& 0C(2f 0 I? 1,q3 OWNER/ OPERATOR FAX # ( 209) 367-5424 San Joaquin General Hospital CHECK If BILLING ADORES FACILITY NAME San Joaquin General Hospital DATE: (it SITE ADDRESS 500W Hospital RD French Camp 95231 Street Number Direction Payment Date Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Check # 3 �'(� �AY x,''11 Street Number Street Name •+I CITY STATE zip PHONE #1 ExT• APN # LAND USE APPLICATION # , n ( 209 468-6812✓oq ` PHONE #2 EXT. ( ) BOS DISTRICT oiJ OFpq NTq� in, CONTRACTOR / SERVICE REQUESTOR ANT REQUESTOR Joseph Bagley, Bagley Enterprises, Inc CHECK if BILLING ADDRESSO BUSINESS NAME Bagley Enter rISeS, Inc COMMENTS: Dates display incorrect on OPW iTouch Tank Monitoring System. Performed Cold Start. All functions normal. PN# ExT. 367-4800 HOME or MAILING ADDRESS 2370 Maggio Cir #4 EMPLOYEE #: r FAX # ( 209) 367-5424 CITY Lodi CA 95240 STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE" FEDERAL laws. APPLICANT'S SIGNATURE: �._ DATE: e-9,4,Pr vi 7 PROPERTY / BUSINESS OWNER❑ OPE TO MANAGER ❑ OTHER AUTHORIZED AGENTEM Contractor IfAPPLICANT is not the BILLING PARTY, proof of authorization 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 SERVICE REQUESTED: COMMENTS: Dates display incorrect on OPW iTouch Tank Monitoring System. Performed Cold Start. All functions normal. ACCEPTED BY: /fi• m M a o 10eum EMPLOYEE #: r DATE: (7 ASSIGNED TO: ' J o 'k� to 1 0 In EMPLOYEE #: 031W DATE: (it Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount:,ODAmount Pa S�. Payment Date 1-7 Payment Type% Invoice # Check # 3 �'(� Rec ived By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003