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,t A <br />+ SAN JOAQUIN&LINTY ENVIRONAIENTAL HEALTH 1* rMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�C f i�TY/ # <br />F4LActive <br />BUSINESS NAME San Joaquin County —PWD Solid Waste <br />SERVICE R—E7QUEST # <br />PHONE # <br />209 <br />Ems' <br />468-3066 <br />HOME or MAILING ADDRESS 1810 E. Hazelton Avenue <br />g- 06/ 9_ <br />Landfill <br />CITY Stockton <br />39—AA-0004 <br />Zip 95205 <br />Date Service Completed (if already completed): <br />OWNER / OPERATOR. <br />ifBILLING ADDRESS® <br />San Joaquin <br />County— Public Works Dept. <br />Solid Waste CHECK <br />FACILITY NAME Foothill <br />Sanitary Landfill <br />ygl� <br />SITEADDRESS 6484 <br />N <br />Waverly Road <br />Check # Seto 0C � 5 <br />Linden <br />T95236 <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 1810 <br />E. Hazelton Avenue <br />Street Number <br />Street Name <br />CITY Stockton <br />STATE CA Zip 95205 <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />.(209 ) 468-3066 <br />09344002 <br />UP3295 & UP3451 <br />PHONE#2 <br />BOS DisTRicT 004 <br />LOCATION CODE 99 <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />Taj M. BahadOri <br />CHECK 1fBILLING ADDRESS ® <br />BUSINESS NAME San Joaquin County —PWD Solid Waste <br />ACCEPTED BY: <br />PHONE # <br />209 <br />Ems' <br />468-3066 <br />HOME or MAILING ADDRESS 1810 E. Hazelton Avenue <br />FAX# <br />( 209) <br />468-3078 <br />CITY Stockton <br />STATE CA <br />Zip 95205 <br />RILl'.JNG ACIXOVVLEDGEMENT: 1, 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 7OAQUIN <br />COUNTY Ordinance Codes, Standards, STATE andzz�' <br />APPJ ICANT3S SIGNATURE:?- <br />OTHERAUTHORMDAGENT M Sr. Solid Waste Eng3.neer <br />PROPERTY / BUSRMS OWNER❑ OPERATOR/ MANAGER ❑ <br />DATE: 9. /24D // 8 <br />If APPLICANT is not theBiLL1NGPARTY proof of authorization to sign is required Title <br />AUTHO��A�.TION TO RELEASE INFOIIIMATION: When applicable, t 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 7OAQUIN 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 />TYPE OF SERVICE REQUESTED: <br />COMMENTS: Installation of two new groundwater monitoring well <br />(mw -4A) on the north side of the landfill.& mw -7 at the <br />southeast side of the landfill. <br />1 �� ► t; / g _ 0 4­�. a'1C Zvi tv - -7 �� ¢--Gt.�v'4s� n , S . �` A -rd Ats <br />ACCEPTED BY: <br />EMPLOYEE#: L��,�a <br />DATE: <br />ASSIGNED 70: —Cie's -0f /!/i � <br />EMPLOYEE #: Zt/d$� <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ?� O <br />P I E: YYO% <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />ygl� <br />Payment Type S'S j <br />Invoice # <br />Check # Seto 0C � 5 <br />Recelved By: 0�j. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />