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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# County Hospital FA0000086 SR0085779 OWNER/OPERATOR San Joaquin General Hospital/Jesse Escotto CHECK if BILLING ADDRESS El FACILITY NAME San Joaquin General Hospital SITE ADDRESS 500 VV Hospital Rd French Camp 95231 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# ( 209 ) 468-7063 PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Joseph Bagley CHECK if BILLING ADDRESS El BUSINESS NAME PHOEXT. Bagley Enterprises, Inc 209 367-4800 HOME or MAILING ADDRESS FAX# 2370 Maggio Cr#4 ( 209) 367-5424 CITY Lodi STATE CA ZIP 95240 EFLLING TT: 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 and FEDERAL laws. /,l-,FT' LC/,1 ,'� '1IGT V-TPE: , ,Qr ;-� xYGZl'� DATE:10/2/23 TY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT X❑_Contractor_ IfAPPLLcANT 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: UST Retrofit-REVISED COMMENTS: Replace monitoring system. 10/2/2023: Replaced monitoring system to install a leak detector.To facilitate the proper functioning of the emergency generator leak detector,the diesel supply line to the back up boiler system will be permanently disconnected from the emergency generator diesel supply line. ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: P 1 E: Fee Amount: Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003