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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 ILA 5 <br /> OWNER / OPERATOR <br /> San Joaquin Regional Transit District ( RTD ) CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> San Joaquin Re ional Transit District RTD <br /> SITEADDRESS 2849 E Myrtle Street Stockton 95205 <br /> Street Number Direction I 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 STATE Zip <br /> 85201 <br /> Stockton CA <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 209 467-6672 157-020- 11 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Joseph Bagley CHECK If BILLING ADDRESS 13 <br /> BUSINESS NAME PHONE # EXT , <br /> Bagley Enterprises Inc 209 367 -4800 <br /> HOME or MAILING ADDRESS <br /> 2370 a io Cir #4 FAx <br /> 209 367=5424 <br /> cITY Lodi CA 95240 STATE ZIP <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 <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 : DATE : � U/ y/� y/ 9 <br /> local <br /> �i —� <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ THER AUTHORIZED AGENT ICI <br /> 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 <br /> above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/sI a assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the �p e it is <br /> provided to me or my representative . dhJ. <br /> TYPE OF SERVICE REQUESTED : UST Retrofit <br /> COMMENTS: Al <br /> Diesel Tank #2 ( DT- 2) Smith Fiberglass product line is fractured and seeping from the top portion of tl�ro�t �r �s�� <br /> piping just forward of the penetration fitting on the inside of the Bravo double wall FRP transition sump im ?Ak <br /> k4 IV <br /> ACCEPTED BY : J V1 �/ l ` EMPLOYEE # : `). �j DATE : + Z � <br /> ASSIGNED TO : O EMPLOYEE # : i V DATE : � 25 Aq <br /> Date Service Completed If already completed) : SERVICE CODE : 2 � g PIE : <br /> Fee Amount : 1+ �2 —� Amount Pal �Stc� d� Payment Date <br /> Payment Type Invoice # Check # 32 3 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />