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t SAN JOAQIL&OUNTY ENVIRONMENTAL HEALTSEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# Sanitary Landfill 39-AA-0004 OWNER/OPERATOR San Joaquin County Department of Public Works J� CHECK if BILLING ADDRREESS❑ FACILITY NAME Foothill Sanitary Landfill SITE ADDRESS 6484 Waverly Road Linden 95236 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 1810 East Hazelton Avenue Street Number Street Name CITY Stockton STATE CA ZIP 95205 PHONE#1 ExT• APN# LAND USE APPLICATION# (209 ) 468-3066 093-440-02 925 PHONE#2 ExT• BOS DISTRICT 4 LOCATION CODE (209 ) 468-8504 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR W Michael Carroll,P.E. CHECK If BILLING ADDRESS BUSINESS NAME San Joaquin County Department of Public Works PHM5# 468-8504 Exr. HOME or MAILING ADDRESS 1810 East Hazelton Avenue FI09 ) 468-3078 CITY Stockton STATE CA ZIP 95205 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 andrFEDEAL law . APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Engineer V If APPLICANT is not the B/LL/NG 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: Inspect installation of tubing to be inserted within existing pipes in existing wells. COMMENTS: Inspection of perforated polyethylene tubes to be installed within existing PVC pipes already installed within existing perimeter soil gas monitoring wells per approved design. ACCEPTED BY: �� Sur3R EMPLOYEE M DATE: ASSIGNED TO: � EMPLOYEE#: J DATE: Date Service Completed (if already completed): Z SERVICE CODE: 3®d P/E: 4Atoo o 7 Fee Amount: J-s 7's— Amount Paid 3 Payment Date Payment Type SsT" Invoice# Check# Received By: p � , EHD 48-02-025 h` SR FORM(Golden Rod) REVISED 11/17/2003