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SAN JOAQ0 COUNTY ENVIRONMENTAL HEALSEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Municipal Solid Waste Disposal <br />V1 EALTH <br />eX57017 <br />Err. <br />JUN 3 0 2009 PERTJiT/SERV+CPS <br />OWNER/ OPERATOR <br />939-9111 <br />Forward, Inc. <br />CHECK if BILLING ADDRESS <br />FAcIUTr NAME Forward Landfill/Austin Road Landfill <br />BY:4` <br />SITE ADDRESS 9999 <br />South <br />Austin Road <br />Manteca <br />95336 <br />Street Number <br />irection <br />EMPLOYEE #: <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />I i E: <br />Fee Amount: <br />3 (S' <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />( 209) 982-4298 <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Ward Herst <br />cZ .v ✓ �S'7-7 <br />CHECK if BILLING ADDRESS 0 <br />BUSINESS NAME Herst & Associates, Inc. <br />V1 EALTH <br />PHONE # <br />Err. <br />JUN 3 0 2009 PERTJiT/SERV+CPS <br />636 <br />939-9111 <br />HOME or MAILING ADDRESS <br />FAx # <br />BY:4` <br />4630 South Highway 94 - North Outer Road <br />( 636 ) <br />939-9757 <br />CITY St. Charles <br />STATE Missouri <br />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: ?i� /�� DATE: 4', <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Managing Director <br />If APPLICANT is not the BILL/NG 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 en o ental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avails s <br />LI I_�l <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: _$ u 1 S l T£ <br />cZ .v ✓ �S'7-7 <br />COMMENTS: <br />V1 EALTH <br />JUN 3 0 2009 PERTJiT/SERV+CPS <br />SAN JOAQtIIN COU S <br />HEALTH <br />HEALTHACCEPTED <br />pE MENTAL <br />BY:4` <br />EMPLOYEE <br />b( <br />ASSIGNED TO: <br />' <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />I i E: <br />Fee Amount: <br />3 (S' <br />Amount Paid <br />e <br />Payment Date 3 �� <br />Payment Type <br />✓ <br />Invoice # <br />Check # D S <br />I Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />