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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 C do �� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> San Joaquin County Fleet Svc—Public Works <br /> FACILITY NAME <br /> San Joaquin Countv Fleet Svc-Co Yard <br /> SITE ADDRESS 1810 1 E I Hazelton Ave Stockton 95205 <br /> Street Number DIrKtio. Stmet Name City ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O.BOX 1610 Street Number Street Name <br /> CITY STATE zip <br /> Stockton CA 95201 <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> ( 209) 468-4645 <br /> PHONE#L EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Joseph Bagley CHECK If BILLING ADDRESS <br /> BUSINESS NAME Bagley Enterprises, Inc PHONE# EXT. <br /> 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 /> 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT 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 locatj3 a above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asses i <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time it is �JLefjj _ <br /> my representative. �tyey 1/� <br /> TYPE OF SERVICE REQUESTED: Spill Bucket replacement S. 1 <br /> COMMENTS: U/NC <br /> <T ON OIJ <br /> The new regulations issued in October 2018 require spill buckets to hold 5 gallons;tank id 508122, Diesel, 15,000 gallon. The c 11 <br /> Wheaton spill container is no longer grandfathered in,therefore,we will replace the spill container and overfill prevention valve with DPW <br /> ACCEPTED BY: fr� .(S [Z, EMPLOYEE DATE: <br /> / <br /> ASSIGNED TO: IL-""-C2.A Ct_. EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: r�� 11 PIE: 2 3 0''9 <br /> r <br /> Fee Amount: A_s r<. . -,--vAmount Paid �Sw-av Payment Date <br /> Payment Type e A—L Invoice# Check# Z 2—j Re ived By: <br /> EHD 48-02-026 SR FORM(Golden Rod) <br /> 07/17/08 <br />