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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # c� SERVICE REQUEST # <br /> County Facility � t� IME1 <br /> OWNER / OPERATOR ` <br /> CHECK if BILLING ADDRESS <br /> Tracy Unified School District <br /> FACILITY NAME <br /> Tracy Unified School District <br /> SITE ADDRESS 1975 W Lowell Ave Tracy 95376 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> P . O . Box 1810 Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA 95201 <br /> PHONE #1 EXT , APN # LAND USE APPLICATION # <br /> ( 209 ) 4684645 <br /> PHONE #2 EXT . BOS DISTRICT �][LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Joseph Bagley CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE # EXT . <br /> Bagley Enterprises , Inc 20 3674800 <br /> HOME or MAILING ADDRESS FAX # <br /> 2370 Maggio Cir #4 ( 209) 367- 5424 <br /> CITY Lodi STATE CA ZIP 95240 <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 or <br /> 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 and FEDERAL laws . ` <br /> APPLICANT ' S SIGNATURE : � `J � DATE : Cl//�i'/ / c;�e/ <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® UST COntraCtOl' <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 located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It Is provided t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : Spill Bucket replacement PAV <br /> COMMENTS : <br /> During monitor certification the diesel spill bucket failed to hold the required live; ' II ' A alj� st be replaced ; we' ll install a new overfill prevention <br /> valve v� �� ,1 d� � � �;� ,,�� <br /> l _, � <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : J (� ` t -� ^ EMPLOYEE # : q001 DATE : I _ <br /> ASSIGNED TO : c EMPLOYEE # : oU` DATE : <br /> Date Service Completed ( if already completed) : SERVICE CODE : PIE : <br /> Fee Amount : Amount Paid *L4 So — Payment Date a I <br /> Payment Type _ Invoice # Check # Received By : lp <br /> EHD 02-025 <br /> 07/ 17/08 ORIGINAL <br />