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SAN JOAQUWQUNTY ENVIRONMENTAL REALTOEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # County Owned Property 00005797 J C, C-) q `r -7 ( 0 OWNER i OPERATOR 1367-4800 CHECKffBILLINGADDRESS SJC Facilities Management FAX q (209 067-5424 CITY Lodi. FACILRY NAME SJC Sheriff's Op's #2 (Jail - Emergency Generator) SITE ADDRESS 7000 I Michael N. QpLU Blvd French Camp 95321 Code Street Number Diltion Payment Type a Invoice # Check # city Zip HOME or MAILING ADDRESS of Different from Site Address) Street Number Street Flame CITY STATE ZIP ExT. P 209468-4637 APN # LAND USE APPLICATION # ) PHONE#2 ExT• BOS DISTRICT / LOCATION COD � ) f CONTRACTOR / SERVICE REQUESTOR REQUESTOR Joe Bagley -Bagley Enterprises, Inc. CHECK if BILLING ADDRESS BUSINESS NAME COMMENTS: Replace missing drop tube with overfill prevention valve. (Excavate north end of tank to expose annular space riser - Remove 2" riser and replace with 4"riser to facilitate R@R of sensor for testing.) PHONE # En. Bagley Enterprises, C 1367-4800 H r MmuNG ADDRESS 178 Maggio Circle, Ste 4, EMPLOYEE #: FAX q (209 067-5424 CITY Lodi. STATE CA ZIP 95240 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 I FEDERAL laws. APPLICANT'S SIGNATU dam' DATE: 2/12/07 2/12/07 PROPERTY / BUSINESS OWNER ❑ OP OTHER AUTHORIZED AGENT 79 Contractor If APPLicANT is not the B G 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: Piping Repair/Retrofit COMMENTS: Replace missing drop tube with overfill prevention valve. (Excavate north end of tank to expose annular space riser - Remove 2" riser and replace with 4"riser to facilitate R@R of sensor for testing.) ACCEPTED El : EMPLOYEE #: C DATE: 2 Q ASSIGNED To• G 1 EMPLOYEE #: rl DATE: Date Service Completed (If already completed): SERVICE CODE: PIE: 2 Fee Amount: 'Z Amount PaidS Payment Date Payment Type a Invoice # Check # q Z Received By: N EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003