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' 1y <br /> �J $- AN JOAQ POUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> swwNMEt,ff <br /> p,LHEpiC.11 SERVICE REQUEST <br /> ' Type of usi perty FACILITY ID# SERVICE REQUEST# <br /> Municipal Solid Waste Disposal r'—cc � <br /> OWNER/OPERATOR <br /> Forward, Inc. CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME Forward Landfill/Austin Road Landfill <br /> ' SITE ADDRESS 9999 South Austin Road Manteca 95336 <br /> Street Number Direction Street Name CI Zip Code <br /> ' HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> ' PHONE#1 EXT. 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 BILLING ADDRESS <br /> BUSINESS NAME Herst&Associates, Inc. PHONE# EXT. <br /> 636 939-9111 <br /> t HOME or MAILING ADDRESS FAX# <br /> 4631 North St. Peters Parkway (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. /` 1/ �,( <br /> APPLICANT'S SIGNATURE: ,� DATE: `( / <br /> tPROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Managing Partner <br /> IfAPPL/CANT 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: PAYMENT <br /> COMMENTS: R 1�1 CI'1(j�� ' 11 1 'I 111 C I QS T v�'� 1 '-t_k `/�-I S' HEGEIVED <br /> ��1 Gi <br /> ' CSX C-(ur i.tJI 1a2 c, 1';�d -k� Jt"��x��; 3S�s �- 2s � G1,,� t:�.,rl„ tJ NOV 11 2011 <br /> �� +t-� G',_p p(1 40 4-h I� �'1 tM �+- EVIIIENO NIMENOANI <br /> HEALTH DEPARTMEN <br /> ' ACCEPTED BY: EMPLOYEE#: DATE: <br /> ' ASSIGNED TO: RAEMPLOYEE M DATE: // b <br /> Date Service Completed (if already completed): SERVICE CODi: P I : O <br /> Fee Amount: Amount Paid Payment Date 17(l <br /> tPayment Type Invoice# Check# v2 02L�8 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />