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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> County Hospital 66r 'VO ( Q s� o'J ogq <br /> OWNER / OPERATOR I <br /> San Joaquin General Hospital/ Jesse Escotto CHECK if BILLING ADDRESS <br /> FACILITY NAME San Joaquin General Hosptial <br /> SITE ADDRESS W Hospital Wy French Camp 95231 <br /> 500 Street Number Direction Street Name Citv Zin Code <br /> HOME Or MAILING ADDRESS ( If Different from Site Address) <br /> Sheet NumberF Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT • APN # LAND USE APPLICATION # <br /> ( 209t 468 -7063 I O 1 <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Ann Marie or Joe CHECK if BILLING ADDRESS <br /> BUSINESS NAME Ba le Enterprises , Inc PHONE # ExT• <br /> 9 y � 20 367-4800 <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 /> 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 `' DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT Contractor/Designated tperator <br /> If APPLICANT is not the BILLING PARTY. proof of authorization to Sigh 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 /> t0 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 : Replace Drop Tube PA I <br /> COMMENTS : q + <br /> SEP 2 ? CL_'. . <br /> e <br /> During the last monitor certification the overfill prevention valve testing failed . Replace failed <br /> OPW 71 SO with like item , ! ' N VI EdON 011 EN1'Al4 ' <br /> Z8 <br /> qoq , 2p <br /> yF44 All CO <br /> ACCEPTED BY: (1 /�� /lam EMPLOYEE #: DATE : �qy 2 �Q� y y <br /> ff <br /> ASSIGNED TO : 01 ai � /�a � /f G ' GJ z? EMPLOYEE #: DATE: (.�/ <br /> Date Service Completed ( if already completed) : v - SERVICE CODE : !G� _ �G� C� / P1 E : 2309' <br /> Fee Amount : #� !� &2 & L . Amount Paid V 00 Payment Date <br /> Payment Type Invoice # Check # Recei ed By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />