CORRESPONDENCE_2017-2018 - Laserfiche WebLink

Home Browse Search

SAN dOAQUIAUNTY ENVIRONMENTAL HEALTH SARTMENT DEC 2 9 2017 SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS TAJ M. BAHADORI SERVIC41114.11, ity' 101 ACTIVE LANDFILL 39—AA-0022 DATE: HONE # P209 EXT. OWNER/ OPERATOR DATE: Date Service Completed (if already completed): SAN JOAQUIN COUNTY—PUBLIC WORKS WASTE HOME or MAILING ADDRESS CHECK If BILLING ADDRESS❑ FACIUTYNAME NORTH COUNTY RECYCLING CENTER & SANITARY LANDFILL Amount Paid SITE ADDRESS 17720 E I HARNEY LANE LODI I STATE /A 95240 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 1810 E. HAZELTON AVENUE Street Number Street Name CITY STOCKTON STATE CA Zip 95205 PHONE #1 ExT. APN # LAND USE APPLICATION # (209 )468-3066 065-120-04 UP -89-2 PHONE #2 EXT• BOS DISTRICT LOCATION CODE ( ) 4 7[99 CONTRACTOR / SERVICE REQUESTOR REQUESTOR & INSPECTIONS CHECK if BILLING ADDRESS TAJ M. BAHADORI ACCEPTED BY: BUSINESS NAME SAN JOAQUIN COUNTY—PWD—SOLID WASTE DATE: HONE # P209 EXT. EMPLOYEE M DATE: Date Service Completed (if already completed): 468-3066 HOME or MAILING ADDRESS P / E: FAX # Amount Paid 1810 E. HAZELTON AVENUE Payment Type (209 1468-3078 CITY S 7&-t /.-- / 0 ^/ STATE /A ZIP 95-.20/ 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 to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. R APPLICANT'S SIGNATURE: I DATE: 7�z��"�� % p PROPERTY/ BUSINESS OWNER ❑ OPERAT R /MANAGER ❑ OTHER AUTHORIZED AGENTQ_ �2 Cr � O%� Q I fneL-_ 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 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: DRILLING PERMIT & INSPECTIONS COMMENTS: INSTALLATION OF ONE NEW GROUND COUNTY LANDFILL WATER MONITORING WELLS AT THE WEST SIDE OF NORTH ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: P / E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003