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SAN JOAQLWOUNTY ENVIRONMENTAL HEALTSEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Sanitary Landfill <br />FACILITY ID # <br />39 -AA -0022. IS <br />CHECK if BILLING ADDRESS® <br />SERVICE REQUEST # <br />OWNER / OPERATOR San Joaquin County Department of Public Works <br />CHECK if BILLING ADDRESS❑ <br />FACILITY NAME North County Sanitary Landfill <br />HOME or MAILING ADDRESS 1810 East Hazelton Avenue <br />SITEADDRESS 17720 <br />Street Number <br />East <br />I Direction <br />Harney Lane <br />I Street Name <br />CITY Stockton <br />Lodi <br />C ity <br />95240 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 1810 <br />Street Number <br />East Hazelton Avenue <br />Street Name <br />CITY Stockton <br />STATE CA ZIP 95205 <br />PHONE #1 ExT• <br />( 209 ) 468-3066 <br />APN # <br />065-120-04 <br />LAND USE APPLICATION # <br />925 <br />PHONE #2 ExT• <br />( 209 ) 468-8504 <br />BOS DISTRICT 4 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR W. Michael Carroll, P.E. <br />COMMENTS: <br />Inspection of perforated polyethylene tubes to be installed within existing PVC pipes already installed within existing <br />perimeter soil gas monitoring wells per approved design. <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME San Joaquin County Department of Public Works <br />DATE: I'l-T--1/2- <br />P##�# <br />Exr. <br />468-3066 - Brian Closs <br />HOME or MAILING ADDRESS 1810 East Hazelton Avenue <br />Date Service Completed (if already completed): —4--// 7112- .Z3 <br />X09 ) <br />468-3078 <br />CITY Stockton <br />STATE CA <br />ZIP 95205 <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 pe ed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE:.3��.00—'o � <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Engineer V <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/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Inspect installation of tubing to be inserted within existing pipes in existing wells. <br />COMMENTS: <br />Inspection of perforated polyethylene tubes to be installed within existing PVC pipes already installed within existing <br />perimeter soil gas monitoring wells per approved design. <br />ACCEPTED BY: /vrii'71L,p c1 Llr�j� Oi H/i i�� <br />EMPLOYEE#: 40B.kJ <br />DATE: I'l-T--1/2- <br />ASSIGNED TO: � -� <br />EMPLOYEE M 4Y6 d'i7 <br />DATE: <br />Date Service Completed (if already completed): —4--// 7112- .Z3 <br />SERVICE CODE: 3 (y.p <br />P I E: 21210 7 <br />Fee Amount: $37S- <br />Amount Paid -j'f -- <br />Payment Date <br />Payment Type 5 r <br />I Invoice # <br />Check # <br />Received By: a <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />