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SAN JOAQUII♦*LINTY ENVIRONMENTAL HEALTH OrPARTMENT SERVICE REQUEST Type of Business or Property N FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # Solid Waste Facility PHONE # ExT. Edgar & Associates ZS— (916)739-1200 HOME or MAILING ADDRESS OWNER/ OPERATOR OWNER/ FAX # 1822 21st Street H Tracy Material Recovery & Transfer Station, Inc. CHECK If BILLING ADDRESS LUX FACILITY NAME DATE: Date Service Completed (if already completed): SERVICE CODE: Tracy Material Recovery & Transfer Facility Fee Amount:. `. Amount Paid — SITE ADDRESS 30703 S. I MacArthur Drive I Check # a Tracy Received By: 95377 Street Number Dire tion Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) P.O. Box 93 Street Number Street Name CITY Tracy STATE CA ZIP 95378 PHONE #1 ExT• APN # LAND USE APPLICATION # (209)835-0601 253-130-19,26 PHONE #2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR N Neil Edgar CHECK If BILLING ADDRESS BUSINESS NAME PHONE # ExT. Edgar & Associates (916)739-1200 HOME or MAILING ADDRESS FAX # 1822 21st Street H ( ) CITY Sacramento STATE CA ZIP 95811 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 and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: -31/7-/-Z':' n PROPERTY / BUSINESS OWNER❑ OP TOR / MANAGER O ® THER AUTHORIZED AGENT ✓e��/ • � �'T k / )2f 6 ?-- I,fAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: Solid Waste Facility Permit Revision N COMMENTS: P 000 C JOPQ�MtiNt SIX io�%VA ACCEPTED BY: EMPLOYEE #: H DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount:. `. Amount Paid — Payment Date 5 Payment Type Invoice # Check # a Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003