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V <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUE # <br />Hospital <br />©�Oj�if <br />HOME or MAILMIG ADDRESS <br />4601 Dale Rd. <br />OWNER / OPERATOR <br />FAX # <br />(209)735-532 <br />CITY Modesto 11 <br />Kaiser Foundation Hospital <br />Date Semite ompieted (if already completed): <br />CHECKif/SlNa ADDRESS <br />FAciuTYNAMIE Kaiser Manteca Medical Center <br />Fee Amoua coo. 472-9-D <br />SITE ADDRESS <br />Paymen Date 9/26/2008 <br />W. Yosemite Ave. <br />Manteca <br />Received By: Web -Sit <br />95337 <br />1777 Street Number <br />Street No m• <br />HOME or MAJUNG ADDRESS of Different from Site Address) <br />Dale Rd. <br />4601 <br />Street Number <br />N • <br />CITY <br />STATE <br />Modesto <br />CA <br />953 <br />PHONE #1 ExT. <br />APN # <br />LAND US <br />(209)735-5314 <br />200-180-34 <br />VAN <br />PHONE 02 Eur.BO <br />I9 ICT <br />LOCATION CODE <br />(209)662-4309 <br />CONTRA R / ARVICE USS R <br />REQUESTOR <br />Mr. Dana G. Feiock <br />CHECK ifBILLMOADDRESS <br />BuswEssNAME Kaiser NFS/Ca ital Pro cit <br />p 7 <br />PH EXT <br />209 735-5314 <br />HOME or MAILMIG ADDRESS <br />4601 Dale Rd. <br />ACCEPTED BY: YEE M <br />FAX # <br />(209)735-532 <br />CITY Modesto 11 <br />STATE CA ZIP 9 <br />BILLING ACKNOWLEDGEMENT: '!e <br />acknowledge that all site and/or projects cif <br />or activity will be billed to me of my busin <br />I also certify that I have pre! <br />COUNTY Ordinance Codes <br />APPLICANT'S SIGNA'Nr <br />PROPERTY/ BUSINESS OWNER <br />If APPLICANT <br />AUTHORJMUON TO R <br />above site adda <br />Its, hereby <br />information to the AN JOAN <br />providoNme or m repres) <br />ST <br />or owner, operator or herr I%�Igeat of same, <br />1. EPARTMENT hourly char ted with this project <br />n. <br />tionAW <br />rformed will be done ' accori#ce with all SAN JOAQUIN <br />E an <br />DA27 <br />tAT / MANAGE OTHER AUTHORIZED A <br />JN PARTY prooNan <br />uthorization to sign is req ire Title <br />N:n applicable, I, the o o erator of the property loci�Yt� <br />release of anyall results, geote a and/or environmental/site <br />ENVIRONMENTAL HEALTH DEPARTME s as it is available and at the same time It is <br />OCT <br />:J b <br />TYPE OF RVICEREQUES ' inS ction of Piping Retrofit S <br />COMMENTS ViR�F_ <br />This p ject c lists f add ng an ditional emergency p generator with new doubl��7C' <br />supply d reI fu pipin from th existing system. The Poc for the new piping will be at the <br />pumps. The xi in fuel a tank d fuel piping ill remain intact as originally designed an <br />installed and no dification o system will c during this project other than what is <br />shown in the new lans and specs 'cations. <br />ACCEPTED BY: YEE M <br />DATE: <br />in <br />ASSIGNED TO: I J #: <br />V <br />Vt <br />DATE: , <br />Date Semite ompieted (if already completed): <br />SERME CODE. <br />P I E: <br />Fee Amoua coo. 472-9-D <br />I Amount Paid <br />Paymen Date 9/26/2008 <br />Payne TypeMasterCar Invoice# 043622 <br />Check# <br />Received By: Web -Sit <br />EH/4f-02-025 SR FORM (Golden Rod) <br />RED 11/17!2003 <br />,DUN Y <br />'4TAL <br />rMFNT <br />