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I <br /> SAN JOAQUI OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Solid Waste Disposal Site �� 6,0Vp )k <br /> OWNER/OPERATOR <br /> Forward Inc . CHECK If BILLING ADDRESS El <br /> FACILITY NAME Forward Landf i 11 <br /> SITE ADDRESS 9999 S . Austin Road Manteca 95336 <br /> Street Number Direction I Street Name city 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 /> (2 09)982-42 98 E. Fanning See JTD Sec 2 .3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR John Boucher CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME SWT Engineering PHONE# Exr. <br /> (909)390-1328 <br /> HOME or MAILING ADDRESS 800-C South Rochester Avenue FAx# <br /> (909)390-3848 <br /> CITY Ontario STATE CA ZIP 91761 <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: 49:�ItR DATE: <br /> PROPERTY/BUSINESS OWNER❑ RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Principal Planner <br /> If APPLICANT is not thIL <br /> e LING 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: in tK 44'-d <br /> COMMENTS: <br /> DEL [ 3 " <br /> SAN JOAQUIN COU <br /> NTy <br /> HEAL7H DEPgR M AL <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: /^J�� DATE: Z 3113 <br /> ASSIGNED TO: EMPLOYEE M vvv DATE: WWI <br /> Date Service Competed (if already completed): SERVICE CODE: SZ P 1 E: <br /> Fee Amount: Amount Paid 6 Payment Date <br /> Payment Type S Invoice# Check# Received By: <br /> Golden Rod <br /> EHD 48-02-025 SR FORM( ) <br /> REVISED 11/17/2003 <br />