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SAN JOAQUINPOUNTY ENVIRONMENTAL HEALTHEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # SERVICE REQUEST # Austin Road Landfill SCS Engineers'461-1297 39 -AA -0001 30 S j�'�C)C+ S r? (5 / e 1 OWNER/ OPERATOR FAX# Fite Circle, Suite 108 Republic/Allied ( 916) 361-1299 CHECK if BILLING ADDRESS FACILITY NAME Date Service Completed (if already completed): Austin Road Landfill P / E: ZZ&07 Fee Amount: SITE ADDRESS 3 , 5 Payment Date r7 9 D Payment Type Invoice # Check # a Li p Received By: S Austin Road Manteca 95336 9069 Street Number Direction Street Name Ci 2i Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE zip PHONE #1 EXT. APN # LAND USE APPLICATION # ( ) ,1Q/ o�,o03 PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR Ambrose A. McCready, P.E. CHECK If BILLING ADDRESS BUSINESS NAME tzlv PHONE# EXT. SCS Engineers'461-1297 30 HOME or MAILING ADDRESS FAX# Fite Circle, Suite 108 DATE: Gt' ( 916) 361-1299 �3�1y17 Sacramento STATE CA ZIP95827 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 plic tiolathat the work to b pe orme will be done in accordance with all SAN JOAQUNCOUNTY Ordinance Codes, Standards STAT aERAL 1 s.APPLICANT'S SIGNATURE: _� r DATE: ? �D� �O l PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUT RIZED AGENT ® COiISultant 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 to the SAN JOAQUN 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: Inspection qY COMMENTS: tzlv 3 hours at $105/hour = $315.00 10t 29 20dyL 0 8 2009 h"�o P;"NIT/SERVICE, Nti1ENT HEA ACCEPTED BY: EMPLOYEE #: DATE: Gt' ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: oO P / E: ZZ&07 Fee Amount: Amount Paid 3 , 5 Payment Date r7 9 D Payment Type Invoice # Check # a Li p Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 DD _TH