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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 Facility <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> San Joaquin County Fleet Svc --Public Works <br /> FACILITY NAME <br /> San Joaquin County Fleet Svc - Cor Yard <br /> SITE ADDRESS 1810 E Hazelton Ave Stockton 95205 <br /> Street Number Direction Street Name Cit Zi 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 /> t ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Joseph Bagley CHECK If BILLING ADDRESS <br /> BUSINESS NAME Bagley Enterprises , Inc PHONE # EXT. <br /> 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: 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 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 <br /> laws , <br /> APPLICANT' S SIGNATURE : )X'C�... .. <br /> . DATE ; @ �2�r.��� el <br /> PROPERTY I BUSINESS OWNER ❑ OPERATQQ/'MANAGER ❑ OTHER AUTHORIZED AGENT ® UST Contractor <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 to me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : Spill Bucket replacement <br /> COMMENTS : <br /> The new regulations issued in October 2018 require spill buckets to hold 5 gallons ; tank id 508122 , Diesel , 15 , 000 gallon . The current Emco <br /> Wheaton spill container is no longer grandfathered in , therefore , we will replace the spill container and overfill prevention valve with OPW products . <br /> ACCEPTED BY : ( C �.` EMPLOYEE #: DATE : <br /> ASSIGNED TO : z n (! . � �/ Ian EMPLOYEE #: o DATE <br /> Date Service Completed ( if already completed ) : SERVICE CODE : P I E : <br /> Fee Amount : _ 4:• , 2? Amount Paid Payment Date <br /> C ;:22 <br /> Payment Type Invoice # Check # M MU C I Y &L ed By : <br /> FEB 19 7039 <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/ 17/08 ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br />