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SAN JOAQIJ&OUNTY ENVIRONMENTAL HEALTSEPARTMENT SERVICE REQUEST Type of Business or Property Sanitary Landfill FACILITY ID # 39 -AA -0003 CHECK if BILLING ADDRESS® BUSINESS NAME San Joa Joaquin Count Department of Public Works - Solid Waste Division q y p SERVICE REQUEST # �0 coCEJ 6 OWNER / OPERATOR San Joaquin County Department of Public Works HOME or MAILING ADDRESS 1810 East Hazelton Avenue CHECK if BILLING ADDRESS❑ FACILITY NAME Harney Lane Sanitary Landfill CITY Stockton STATE CA SITEADDRESS 44,32@ j 730 Street Number East Direction Harney Lane Street Name Payment Date Lodi C ity Invoice # 95240 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 1810 Street Number East Hazelton Avenue Street Name CITY Stockton STATE CA ZIP 95205 PHONE #1 ExT• ( 209 ) 468-3066 APN # 065-030-03 LAND USE APPLICATION # 925 PHONE #2 ExT• ( 209 ) 468-8504 BOS DISTRICT 4 11 LOCATION CODE 99 CONTRACTOR / SERVICE REQUESTOR REQUESTOR W. Michael Carroll, P.E. COMMENTS: Inspection of perforated polyethylene tubes to be installed within existing PVC pipes already installed within existing perimeter soil gas monitoring wells per approved design. CHECK if BILLING ADDRESS® BUSINESS NAME San Joa Joaquin Count Department of Public Works - Solid Waste Division q y p PH��# EM' 468-3066 - Brian Closs HOME or MAILING ADDRESS 1810 East Hazelton Avenue 1149 ) 468-3078 CITY Stockton STATE CA ZIP 95205 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 t be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Engineer V If APPLICANT is not the BILLING PARTY, proof of authorization 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 t0 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: Inspect installation of tubing to be inserted within existing pipes in existing wells. COMMENTS: Inspection of perforated polyethylene tubes to be installed within existing PVC pipes already installed within existing perimeter soil gas monitoring wells per approved design. ACCEPTED BY:A�JdH SLd13/d9!/✓dA0✓ EMPLOYEE #: "1�� O DATE: ASSIGNED TO: 4�7;11z-,A �is/3iS 4i ��• EMPLOYEE#: 4"Is-0 DATE: Date Service Completed (if already completed): 5/1y6/1 2. A"'>" SERVICE CODE: 3 Q,� P 1 E: Fee Amount: j 75" Amount Paid 3 j� — Payment Date Payment Type j�jT Invoice # Check # Received By: t6,_ EHD 48-02-025 4v be. Ult� SR FORM (Golden Rod) REVISED 11/17/2003