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SAN JOAQUI" tOUNTY ENVIRONMENTAL HEALTHOPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # Rudy Coto SERVICE REQUEST # Sanitary Landfill PHONE# EXT. 0 SEP - 3 2009 909 860-7777 x 211 HOME or MAILING ADDRESS SAN JOAQUIN COUNTY OWNER/ OPERATOR 1360 Valley Vista Dr*ve ENVIRONMENTAL HEALTH DEPARTMENT CHECK If BILLINGADDRESS� Allied Waste Industries STATE ZIP FACILITY NAME CA 91765 Forward Landfill DATE: SITE ADDRESS SERVICE CODE: co South 9999 Austin Road Manteca 95202 Street Number Direction Street Name HOME or MAILING ADDRESS (If Different from Site Address) city Zip Code 6800 Street Number Koll Cyet.QJg g@rkway CITY Pleasanton STATE ZipCA Check # el L q `9 94566 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 925 ) 201-5823 201-060-002 PHONE #T EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE RF.OTTF,QTnR REQUESTOR Rudy Coto CHECK if BILLING ADDRESS D BUSINESS NAME PHONE# EXT. BAS & Associates SEP - 3 2009 909 860-7777 x 211 HOME or MAILING ADDRESS SAN JOAQUIN COUNTY FAX # 1360 Valley Vista Dr*ve ENVIRONMENTAL HEALTH DEPARTMENT (90 ) CITY Diamond Bar STATE ZIP DATE: CA 91765 BILLING ACKNOWLEDGEMENT: 1, 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 this4applicationthe work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, StandardsL laws.APPLICANT'S SIGNATURE: DATE::`� ( / zofPROPERTY /BUSINESS OWNER ❑ R ❑ OTHER AUTHORIZED AGENT LYJ If APPLICANT is not theBILLINGPARTY. proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INIF'ORMATION: 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 to me or my representative. TYPE OF SERVICE REQUESTED: PAYMENT COMMENTS: SEP - 3 2009 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: % ;� �� EMPLOYEE M DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: co / E; D Fee Amount: Jj 1{ 5 �- Amount Paid 345 Payment Date ck 3 Payment Type Invoice # Check # el L q `9 Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)