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It <br />• <br />0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />BUSINEss NAME SAN JOAQUIN COUNTY -PWD -SOLID WASTE <br />�Atx� ll <br />��g 66'74 <br />ACTIVE LANDFILL <br />•-3�'9�1r <br />3� <br />-1 _ n.S 3/6// <br />3 1 / 11 --f 374411 <br />OWNER /OPERATOR <br />SAN JOAQUIN COUNTY -PUBLIC WORKS SOLID WASTE CHECK If BILLING ADDRESS <br />FAciuTY NAME NORTH COUNTY RECYCLING CENTER & SANITARY LANDFILL <br />SITE ADDRESS <br />STATE CA <br />ZIP 95201 <br />DATE: /� Z `� <br />ASSIGNED TO: J le /5 A.0. Ay1' A <br />77, <br />17'SGOt Number <br />Direct,. E <br />HARNEY SCe"si ame <br />ANN. <br />T <br />LO�II <br />/� <br />9� C oOee <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P I E: 40 i'Vz'' 7 <br />1$10 <br />E. HAZELTON AVENUE <br />Street Number <br />Stroot Name <br />CITY STOCKTON STATE CA ZIP 95205 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(209) 468-3066 <br />065-120-04 <br />UP -89-2 <br />PHONE#2 ExT. <br />BOS DISTRICT 4 <br />LOCATION CODE <br />1 ) <br />99 <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR TAJ M. BAHADORI <br />CHECK If BILLING ADDRESS <br />BUSINEss NAME SAN JOAQUIN COUNTY -PWD -SOLID WASTE <br />.�%I //4 ©lferv�.• �•>< G -� .:y�l`�t <br />PHONE# <br />09 <br />EXT. <br />468-3066 <br />HOME or MAILING ADDRESS <br />1810 E. HAZELTON AVENUE <br />3� <br />-1 _ n.S 3/6// <br />3 1 / 11 --f 374411 <br />FAX # <br />(209 <br />)468-3078 <br />CITY STOCKTON <br />STATE CA <br />ZIP 95201 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />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 <br />COUNTY Ordinance Codes, Standards, STATE anddFFEDER L la s. <br />APPLICANT'S SIGNATURE: /'[ . DATE: 1// Z f j8 <br />PROPERTY IBUSINBSSOWNER13 OP ATOR/MANAGER ❑ OTHERAuTHoumm) AGENT 10 SENIOR ENGINEER <br />IfAPPLICANT is not the BILLING PAR7Y. proof of authorization to sign is required 7711e <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />I TYPE OF SERVICE REQUESTED: TIUTT T TAT101 DLDMTT L TTQCPT?t' VTnM_Q l <br />COMMENTS: <br />INSTALLATION OF THREE (3) NEW GROUND WATER MONITORING WELLS AT NORTH COUNTY <br />LANDFILL. G1 <br />.�%I //4 ©lferv�.• �•>< G -� .:y�l`�t <br />.G6A;.-&--G3&-W98T--91DE:-W_1 <br />N�M <br />3� <br />-1 _ n.S 3/6// <br />3 1 / 11 --f 374411 <br />3 J P k -e S_d <br />- 3��-r - f 113 -fg—t - t <br />it" <br />ACCEPTED BY: <br />EMPLOYEE #: �.� <br />DATE: /� Z `� <br />ASSIGNED TO: J le /5 A.0. Ay1' A <br />EMPLOYEE M d <br />DATE: * / 22 /g <br />Date Service Completed (if already completed'/:RVICE <br />SECODE: ,?lop <br />P I E: 40 i'Vz'' 7 <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />InVOice # <br />Check # <br />Received By: <br />EHD 48-02-026 SR FORM (Golden Rod) <br />REVISED 11/1712003 <br />-11, 3j.' I <br />