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SERVICE REQUEST <br /> Type o- <br /> f Business or Property FACILITY ID# J�� SSERVICE REQUEST# <br /> Solid Waste F '3 00/1k 2 1n <br /> Bt I I G PARTY <br /> OWNER/OPERATOR C3 <br /> Forward Inc. <br /> FACILITY NAME <br /> Forward Landfill <br /> SGE ADDRESS <br /> 9999 SN a,s„ Austin Roadsbvd ru. <br /> Mailing Address (If Different from Site Address) <br /> Cay <br /> TATE CA ZIP 95336 <br /> Manteca <br /> PHONE#1 T APN# LAND USE APPuCATION# <br /> ( 209 466-4482 1201-060-03 U-91-12 <br /> PHONE#2 <br /> SOS DISTRIOr _ LOCATION CODE, <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REQUESTOR Bu-Lm PARTY❑ <br /> BUSINESS NAME PHONE# oa <br /> MAILING ADDRESS FAx <br /> CITY , s STATE ZIP <br /> C- J <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned properly or business owner,operator or authorized agent of same,adoaMedge that ad site and/or projed specific <br /> PUBuc HEALTH SERVICES ENVIRcNk4ENTAL HEALTH DmsioN hourty diarges associated with this p*d or acdvity will be billed to me or my business as identified on this farm <br /> I also certify that I have prepared this appficathon and that the work OD be performed vid be done in aomrdarwe with aA SAN JOAam COUNTY Ordinenoe Codes,Standards,STATE and <br /> FEDERAL.laws. C� <br /> APPLICANT SIGNATURE: �� � ,�• DATE: )22/ 1)i <br /> PROPERTY IBusINEssOHrtrER ❑ OPEFWOR(MANAGEFt OTHERX cFjzEDAGENT O �k !' 1191' <br /> XAPPLCANrisaaV*6LIJ'SiP produ(wahorfudwrtompnbnqu&W TlGe <br /> AUTHORIZATION TO RELEASE INFORMATION:When appbcable.1.the owner or operatoraf the prop"located at the above site address.hereby authorize the rebase of <br /> any and aA rh sWM geotechnical data an,Uor envitanmentallsite assessment infornhawn to the SAN JOAamh COUNTY Poet IC HEALTH SeRVICFs ErnnRO►u+EMK HEALTH DmStON as soon <br /> as it Is available and at the same time it is VvMed to me or my representabe. <br /> TYPE OF SERVICE REQUESTED: <br /> e f2 <br /> COMMENTS: �!�j r i l/��f'`/ Cif//'J `%?t/'V►"''� oN�%v v�� E <br /> RE EIVED <br /> 2� <br /> 2 2 2001, <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ':WIPONMENTAL HEALTH DVISION <br /> INSPECTOR'S SIGNATURE CONTRAGroses SSoNATURE: J <br /> APPROVED BY: EmKZY--#: / l DATE' D/ <br /> ASSIGNED TO: 11 EMPLOYEE#: DATE: ±'P <br /> Date Service Completed (rE alrt�dy completed): SERVICECODE: r J� F- <br /> Fee Amount: Amount Paid �� Payment Date )-10 <br /> Payment Type Invoice 4 Check# 5 Received By: <br />