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SAN JOAQUINOUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY iD I# SERVICE REQUEST II <br /> County owned Facility FA0003787 S co 'S iefS 2,. <br /> OWNER/OPERATOR13 <br /> SJC Public Works (Dan McCann - Fleet Manager) CHECK if BaLII�ADDRESS <br /> FACILITY NAME Sheriff's Operations Fueling Facility <br /> SITE ADDRESS <br /> 7000 Street Number Michael C i Rd French p 9 1 <br /> HOME Or MmultG ADDRESS (if Different from Site Address) <br /> Street Number stmetHann <br /> CITY STATE ZIP <br /> PHONE#1 �' APN# LAND USE APPLICAnoN# <br /> ( } 193-050-14 <br /> PHONE#2 aT SOS DISTRICT LOCATION CODE <br /> C 91 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> Joseph Bagley <br /> BUSINESS NAME PHONE# ' <br /> Bagley Enterprises, Inc. (209 )367-4800 <br /> HOME or MAILING ADDRESS FAX# <br /> 2370 Maggio Circle, it4 (209 )367-4800 <br /> C% <br /> di di sTA to 7'35240 <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,STATE d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2/2/09 <br /> POpERTYIBt=NmpwNER❑ Orme :::] ER�OTmm 0AunwRma)AGENTKP Contractor <br /> If APPLic*,T is not the BH L WG P.9RT Y,proof ofmahorimfion to sign is requered Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED= UST Repair �f,ST rbc% <br /> COMMENTS:ming Annual Monitor Certification, Annular Sensor failed. REquest RtigWIRD <br /> remove and replace Veeder Root Sensor #794390-409. FEB 03 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: r,L �- EIYtl'LOYEE#: 3Z DATE: Zlo <br /> - <br /> ASSIGNED TO: �, �, EIlf>PLOYEE M � �V 2__ DATE: 2-1 C,r <br /> Date Service Completed (if kready completed): SERVICE CODE: (d ts- <br /> PIE: <br /> > y <br /> Fee Amount: 3 f S t; Amount Paid is Payment Date 2/ 3 <br /> Payment Type invoice# Check# 22 Z Received By: — <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/200:1 <br />