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SAN JOAQU LINTY ENVIRONMENTAL HEALTH OARTMENT 0131 %— I .T.yt Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS SERVICE REQUEST # County Owned Facility'��-2 PHONE # g09 ExT' 367-4800 HOME or MAILING ADDRESS OWNER/ OPERATOR FAX# SJC Public Works ( Dan McCann - Fleet Manager) CHECK if BILLING ADDRESS FACILITY NAME C09 Corporation Yard CITY Lodi $ T DDRESS ZIP 959.40 Hazelton AvstieetName Invoice # Stockton 95Zp 2.�0� Street Number Direction de HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT• APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR i REQUESTOR Joseph Bagley COMMENTS: During testing of 87 Octane Product Line Leak Detector failed. Verbal approvaiwas CHECK if BILLING ADDRESS SI SS NAME Bagley Enterprises, Inc. remove existing gasoline and vapor bucket sump manhole covers and replace with covers PHONE # g09 ExT' 367-4800 HOME or MAILING ADDRESS DATE: FAX# EMPLOYEE #: / 2370 Maggio Circle Ste 4 Date Service Completed (if already Completed): C09 )367-5424 CITY Lodi STATE C;A ZIP 959.40 BILLING ACKNOWLEDGEMENT: 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. APPLICANT'S SIGNA ` DATE; 3/28/08 PROPERTY / BUSINESS OWNER❑ O TOR / MANAGER ❑ OTHER AUTHORIZED AGENT M Contractor If APPLICANT is not the BILLnVGPARTY proof of authorization to sign is required Tette AUTHORIZATION TO RELEASE INFORMATION: When applicable, L 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: S COMMENTS: During testing of 87 Octane Product Line Leak Detector failed. Verbal approvaiwas given by SJC-OM for a permit to be applied forfand issued within 48 hours. The Leak Detector was removed and replaced with a like item, tested and passed.In addition, remove existing gasoline and vapor bucket sump manhole covers and replace with covers that have removeable inspection plates. Doing so may entail replacement of spill buckets. ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO:f'✓ EMPLOYEE #: / DATE: Date Service Completed (if already Completed): SERVICE CODE: 7� P / E: -2 L or -` Fee Amount: n' Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003