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• • <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT P <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Active Landfill <br />CHECK if BILLING ADDRESS® <br />-3�=�C� <br />JP-D67/OC")- <br />PHONE# <br />EXT. <br />San Joaquin County -PWD Solid Waste <br />ACCEPTED BY: <br />209 <br />OWNER / OPERATOR <br />HOME or MAILING ADDRESS <br />EMPLOYEE#: �/,��� <br />San Joaquin <br />CHECK if BILLING AD DREss ❑ <br />County—Public Works Dept. Solid Waste <br />FACILITY NAME <br />(209) <br />Foothill Sanitary <br />Landfill <br />STATE CA <br />SITEADDRESs 6484N <br />I <br />Waverly Road <br />Linden <br />T95236 <br />Straat Number DirectignStreet <br />Name <br />city <br />HOME or MAILING ADDRESS (if Different from <br />Site Address) <br />1810StraetNumber <br />E. <br />Hazelton AlFr et Name <br />CITY <br />STATE ZIP <br />Stockton <br />CA 95205 <br />PHONE#1 EXT. <br />APN# <br />LAND USE APPLICATION# <br />(209) 468-3066 <br />09344002 <br />UP3295 & UP3451 <br />PHONE#2 EXT• <br />BOSDISTRICT <br />LOCA�?CODE <br />( ) <br />004 <br />yJ <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />COMMENTS: Drilling of exploratory borings south of Module 2A. Borings will be backfilled <br />Tal M. Bahadori <br />CHECK if BILLING ADDRESS® <br />BUSINESS NAME <br />/f/S 0/i 7 - 2 _�' -A4 <br />PHONE# <br />EXT. <br />San Joaquin County -PWD Solid Waste <br />ACCEPTED BY: <br />209 <br />468-3066 <br />HOME or MAILING ADDRESS <br />EMPLOYEE#: �/,��� <br />FAX# <br />Date Service Completed of already completed): /-2////7 <br />1810 E. Hazelton Avenue <br />(209) <br />468-3078 <br />CITY Stockton <br />STATE CA <br />Zip 95205 <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 applicatio Ind that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S an FFEAS <br />APPLICANT'S SIGNATURE: a DATE: t f -le-17 <br />PROPERTY/ BUSINESS OwNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ®Sr.Solid Waste Engineer <br />IfAPPMCANT is not the BILLBMPARTY, proof of ar[tloorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 />TYPE OF SERVICE REQUESTED: Drilling Permit & Inspections <br />COMMENTS: Drilling of exploratory borings south of Module 2A. Borings will be backfilled <br />with neat cement. <br />7 Cw.,,4 a,44 /3 J - `/-2B117 - a. s A -n - �s <br />/f/S 0/i 7 - 2 _�' -A4 <br />���-r � �'n•T C LA G 1 - /2/1/,,7 - .?. S'l-� r - A'1 <br />ACCEPTED BY: <br />EMPLOYEE #: <br />E: I t l 2-o/t <br />ASSIGNED TO: /`'� L+%4 �ui2 �lf.�rrn Yl9 <br />EMPLOYEE#: �/,��� <br />DATE: // 2-0/17 <br />Date Service Completed of already completed): /-2////7 <br />SERVICE CODE: 3 t D <br />P / E: 1/144 <br />Fee Amount: 7 ,. Amount Paid i — Payment Date <br />/ / .2-0 / 7 <br />Payment Type LJ s-'' invoice # Check # ljg;1fDoo 1,5) 3 <br />Received By: IBJ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />