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t SAN JOAQUV&UNTY ENVIRONMENTAL HEALTH WARTMENT SERVICE REQUEST Type of Business or PropertyLITY ID BUSINESS NAME SAN JOAQUIN COUNTY -PWD -SOLID WASTE EERVII�# SERVICE PHONE# 09 E"T. 468-3066 FZ # DATE: B,` 607W ACTIVE LANDFILL CITY STOCKTON STATE CA zip 95201 W OWNER /OPERATOR OWNER /1 -7 -if J) b . Payment Type 6S -r- SAN JOAQUIN COUNTY -PUBLIC WORKS SOLID WASTE CHECK if BILLING ADDRESS FACILITY NAME NORTH COUNTY RECYCLING CENTER & SANITARY LANDFILL SITE ADDRESS 17720 E HARNEY LANNE LOD� 952240 Street Number Direction Street ame Ci i ode HOME or MAILING ADDRESS (If Different from Site Address) 1810 E. HAZELTON AVENUE Street Number Street Name CITY STATE Zip STOCKTON CA 95205 PHONE #1 EXT. APN # LAND USE APPLICATION # (209) 468-3066 065-120-04 UP -89-2 PHONE #2 ExT. BOS DISTRICT 4J LOCATION CODE ( ) 99 CONTRACTOR / SERVICE REQUESTOR REQUESTOR TAJ M. BAHADORI CHECK if BILLING ADDRESS® BUSINESS NAME SAN JOAQUIN COUNTY -PWD -SOLID WASTE EMPLOYEE #: PHONE# 09 E"T. 468-3066 HOME or MAILING ADDRESS 1810 E. HAZELTON AVENUE DATE: FAX # (209 )468-3078 CITY STOCKTON STATE CA zip 95201 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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE andel FJEDE L la s. APPLICANT'S SIGNATURE: i� / (. DATE: I // 2-A? PROPERTY/ BUSINESS OWNER OP TOR /MANAGER ❑ OTHER AUTHORIZED AGENT ® SENIOR ENGINEER 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 THREE (3) NEW GROUND WATER MONITORING WELLS AT NORTH COUNTY LANDFILL. G1B-EAST SIDE OF LANDFILL G6A & G3E WEST SIDE OF LANDFILL ACCEPTED BY:ofl� EMPLOYEE #: DATE: ASSIGNED TO: /�� ✓ EMPLOYEE M 4j6 � DATE: Date Service Completed (if already completed): SERVICE CODE: � P I E: 7 Fee Amount: 1052 Amount Paid �'15� _. 1 Payment Date /1 -7 -if J) b . Payment Type 6S -r- Invoice # Check # 5qtLW I5� Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003