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SAN JOAQUI&OUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Municipal Solid Waste Disposal -71 V �y'ZO0 ct /42- <br /> OWNER/OPERATOR ❑ �a <br /> Forward, Inc. D CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Forward Landfill/Austin Road Landfill <br /> AN 0 S 2010 <br /> SITE ADDRESS 9999 South Austin Road 1}[/� Manteca 95336 <br /> Street Number Direction Str ONAENT f�ILr1 H city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) rtmm 11[bMillin <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> (209 ) 982-4298 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Ward Herst CHECK if BILLINGADDRESSE] <br /> BUSINESS NAME Herst&Associates, Inc. PHONE# Exr. <br /> 636 939-9111 <br /> HOME or MAILING ADDRESS FAX# <br /> 4630 South Highway 94-North Outer Road (636 ) 939-9757 <br /> CITY St.Charles STATE Missouri Zip 63304 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Managing Director <br /> If APPLICANT is not the BILLING 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: p �(�IERE NT <br /> COMMENTS: <br /> JAN 13 2010 <br /> S�'ENVIR NME �NT <br /> HATH DEPAR <br /> ACCEPTED BY: O, EMPLOYEE#: 89-75 DATE: <br /> ASSIGNED TO: t 1 EMPLOYEE#: 262-0 <br /> 6 DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: `� PIE:y440-7 <br /> Fee Amount: 3�� _ Amount Paid 3 � S Payment Date , o <br /> Payment Type Invoice# Check# \ Received By: ��— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />