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SAN JOAQUIAOOUNTY ENVIRONMENTAL HEALTHOPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # PHONE # EXT. (209) 468-3066 SERVICE REQUEST # FAx# ( ) CITY Stockton STATE CA ZIP 95205 2 Active Landfill 39—AA-0004 DATE: I�/��// -7( Date Service Completed (if already completed): OWNER / OPERATOR San Joaquin County -Public Works Dept. Solid Waste CHECK if BILLING ADDRESS❑ FACILITY NAME Amount Paid I Foothill Sanitary Landfill / / / 7 SITE ADDRESS Invoice # 7- Check # S&ftDD/_'59-7 Received By: 6484N Waverly Road Linden 95236 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 09344002 UP3295 & UP3451 PHONE#Y EXT. ( ) BOS DISTRICT 004 [LOCATION CODE99 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Taj M. Bahadori CHECK if BILLING ADDRESS BUSINESS NAME San Joaquin County -PWD Solid Waste PHONE # EXT. (209) 468-3066 HOME or MAILING ADDRESS 1810 E. Hazelton Avenue FAx# ( ) 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, ST� gfI1FFEQ) RAL 1 ws. APPLICANT'S SIGNATURE:4 L. DATE:10�Z-5 2 PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 63 S r . Solid Waste Engine e r 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:Review of Foothill's permit documents COMMENTS: Revised closure & post closure documents provided on 3/15/17. err / D /R 7 // % ACCEPTED BY: 7�^�t L ,r r^� ir+ EMPLOYEE #: �/f_g 'J O/3o// -7 DATE: "0/?0//7 ASSIGNED TO: /�� RID _!Y," EMPLOYEE #: �� fl DATE: I�/��// -7( Date Service Completed (if already completed): SERVICE CODE: 'S"__3 P / E: 41 d6 Fee Amount: 'S 3-0q Amount Paid I Payment Date / / / 7 Payment Type Invoice # 7- Check # S&ftDD/_'59-7 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003