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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property _ FACILITY ID # SERVICE REQUEST # County Jail OWNER / OPERATOR CHECK if BILLING ADDRESS SEES San Joaquin County Sheriffs Ops #2 FACILITY NAME San Joaquin County Sheriffs Ops #2 SITE ADDRESS N Michael Canlis Blvd French Camp 95231 7000 Street Number Direction I Street Name Cit Zip Code HOME Or MAILING ADDRESS ( If Different from Site Address) S Wilson Wy Ste 590 444 Street Number Street Name CITY Stockon STATE ZIP CA 95205 PHONE #1 ExT• APN # LAND USE APPLICATION # ( 209) 468-3357 PHONE #2 ExT• BOS DISTRICTG3 LOCATJQN NODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Ann Marie or Joe CHECK if BILLING ADDRESS BUSINESS NAMEBagley Enterprises , Inc PHONE # ExT. 20 367-4800 HOME or MAILING ADDRESS FAX # 2370 Maggio Cir #4 ( 209) 367-5424 CITY Lodi STATE CA ZIP 95240 Ffl_I_I [\rG A. GKI\r ( ) Vi/ I_FDI= F\rFI�r T : 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 . 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 . A P l- I Ch, fir i ` (✓ � f G- f\I`ATU F (_ : DATE : 10/19/2021 PROPERTY I BUSINESS OWNER 13ER TOR / MANAGER ❑ ER AUTHORIZED AGENT �I Contractor/Designated Operator If APPLICANT is not the BIL- NG PARTY, proof of authori ' tion to sign is required Title AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , 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 t0 me Or my representative . TYPE OF SERVICE REQUESTED : Replace Drop Tube S / / ,,e COMMENTS : During the last monitor certification the overfill prevention valve testing failed on the South Tank ID TA0504968 -20 , 000gl Diesel . Replace failed OPW 71 SO with new. ACCEPTED BY : /! �J )VI � EMPLOYEE #: DATE: ASSIGNED TO : G I t / / t� Y� EMPLOYEE #: DATE: Date Service Completed ( if already Completed) : SERVICE CODE : Iq04a2!51� f PIES Fee Amount : vY �J� Amount Pal Payment Date Payment Type Invoice # Check # Received By : - EHD 48-02-025 SR FORM (Golden Rod) 07/17/08