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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Commercial FA0022301 �EU07q 7v <br /> OWNER/OPERATOR <br /> San Joaquin Regional Transit District (RTD) CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME San Joaquing Regional Transit District (RTD) <br /> SITE ADDRESS 2849 E Myrtle Street Stockton 95205 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P 0 Box 201010 Street Number Street Name <br /> CITY Stockton CA 95201 STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 209 467-6672 157-020-11 <br /> PHONE#2 ExT• BOS DISTRICT ` LOCATION CODE <br /> ( ) 1 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Joseph Bagley CHECK if BILLINGADDRESS� <br /> BUSINESSNAME Bagley Enterprises, Inc PHO2' -367-4800 EXT. <br /> HOME or MAILING ADDRESS 2370 Maggio Cir #4 Ax 0�1-367-5424 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ( ��7 47 DATE: O �C/f3 <br /> PROPERTY/BUSINESS OWNER OP TOR/MANAGER ❑ OTHER AUTHORIZED AGENT IR Contractor <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of therty located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environt <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an a W L) <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST Retrofit <br /> COMMENTS: flutyMENTAL H <br /> PERMiT/SERVICES H <br /> Diesel leak inside the Diesel Transition Sump in the Filter Room; see scope of work attached. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: C ._ _ 1 S •/ <br /> Date Service Completed (if already completed): SERVICE CODE: l of P I E: C2 <br /> Fee Amount: 5 Amount Pai �, U Payment Date <br /> Payment Type Invoice# Check# 31,51D Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />