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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTH I> PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />COMMENTS: O IL L I/I�C� PGI/*% /% L7P <br />�61;2/2^e L . GSC -re- <br />�5-6'k%lit` 3 .i - Cid L1�L'✓15Ice, L <br />W Michael Carroll <br />FACILITY ID # <br />SERVICE REQUEST # <br />Closed LandfillAA0003698 <br />PHONE # EXT. <br />San Joaquin CountV <br />39 -AA -0005`` <br />z -. (�- <br />3( O� 42 <br />OWNER / OPERATOR <br />Fee Amount: t_. U v <br />FAX # <br />San Joaquin County <br />Public <br />CHECK If BILLING ADDRESS❑ <br />Works Department Solid Waste Division <br />FACILITY NAME <br />Corral 'Hollow Sani <br />Tand <br />ill <br />SITE ADDRESS 31130rQ11rection <br />uth <br />Corral Hollow Road <br />Tracy <br />95377 <br />Street Number <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from <br />Site Address) 1810 <br />E Hazelton Ave <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />Stockton <br />CA 95205 <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />(209 )468-3066 <br />1253-030-10 <br />PHONE #2 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />5 <br />99 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />COMMENTS: O IL L I/I�C� PGI/*% /% L7P <br />�61;2/2^e L . GSC -re- <br />�5-6'k%lit` 3 .i - Cid L1�L'✓15Ice, L <br />W Michael Carroll <br />CHECK If BILLING ADDRESS ❑ <br />BUSINESS NAME <br />ASSIGNED TO: /v�-e, ,, Q4ee-o <br />PHONE # EXT. <br />San Joaquin CountV <br />Public Works De artment Solid Waste <br />6 - <br />20 468-3066 <br />HOME <br />HOME or MAILING ADDRESS <br />Fee Amount: t_. U v <br />FAX # <br />1 <br />PaymentType-lj�j j' <br />() 469-1079 <br />CITY Stockton <br />STATE CA ZIP 95201 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDE a s. <br />APPLICANT'S SIGNATURE: DATE: <br />11-14-2012 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZEDAGENT13 Senior Civil Engineer <br />IfAPPL/CANT is not the B/LLING PARTY, proof of authorization 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:/,r2 <br />COMMENTS: O IL L I/I�C� PGI/*% /% L7P <br />�61;2/2^e L . GSC -re- <br />�5-6'k%lit` 3 .i - Cid L1�L'✓15Ice, L <br />ACCEPTED BY: (�� 4 <br />EMPLOYEE #: !7/6�o <br />DATE: 1111, <br />ASSIGNED TO: /v�-e, ,, Q4ee-o <br />EMPLOYEE #: L,L6 � <br />DATE: Yll "113 <br />Date Service Completed (if already completed): <br />SERVICE CODE: J aO <br />P / E: / l p % <br />Fee Amount: t_. U v <br />Amount Paid ?j-75 _. <br />Payment Date 15--'>T- <br />STPayment <br />PaymentType-lj�j j' <br />Invoice # <br />Check # <br />Received By: <br />sckoob l D(Z. <br />EHD 48-02-025 - ` ,�� / SR FORM (Gollde�n.Rod) <br />REVISED 11/17/2003 g� ��f3 — 0�$�Y•�OS �" 0-/ �"�'r'� �� �G - �j' el. 1r�7 <br />