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SERVICE REQUEST RC.� �' . e 93 <br />rACILITY ID # V / y RECORD ID # q y��3 �� INVOICE k <br />FACILITY NAME Lovelace Transfer Station <br />k"AC <br />Y / <br />ILN) <br />SITE. ADDRESS 2323 E. Lovelace Road i <br />CITY Manteca cA zIP 95336 <br />OWNER/OPERATOR San Joaquin County Solid Waste Division <br />DBA Lovelace Transfer Station Renovation <br />ADDRESS P.O. Box 1810 <br />CITY Stockton <br />APN # -,P <br />STATE CA <br />Lend Use Application # <br />CONTRACTOR and/er <br />SERVICE REOUESTOR San Joaquin County Solid Waste Division <br />KILLING PARTY Y / (N) <br />pNpgE #1 ( 209 ) 468 _ 3066 <br />PIIONE k2 ( ) <br />zlP 95201 <br />BILLING PARTY k Y ) / N <br />pgp <br />Fund <br />021 <br />Budget IInit 000051 <br />PHONE <br />#1 <br />BOS <br />Dist <br />t.0 <br />468 - <br />Location <br />Code <br />Check # <br />Recvd By <br />MAILING ADDRESS <br />P.O. <br />Box <br />1810 <br />FAX <br /># <br />BILLING PARTY k Y ) / N <br />pgp <br />Fund <br />021 <br />Budget IInit 000051 <br />PHONE <br />#1 <br />( <br />209 <br />> <br />468 - <br />3066 <br />Receipt k <br />Check # <br />Recvd By <br />MAILING ADDRESS <br />P.O. <br />Box <br />1810 <br />FAX <br /># <br />( <br />209 <br />> <br />468_ <br />3078 <br />clTr Stockton s7nrE CA zIP 95201 <br />KILLING ACKNOWLEDGEMENT: 10 the Undersigned owner, operator or agent of same, acknowledge that all site end/or project specific <br />PIIS/F.HD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />Page 1 of this form. <br />I also certify that I have prepared this appllcetian end that the Nork to be performed will be done in ectordance with ell SAN <br />JOAWIN CWNTY Ordinance Codes and Standards, �Stry4e end Federal laws. <br />APPLICANT f <br />S SIGNATURE <br />Title: Solid Waste Manager <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the <br />above, when applicable, I, the owner, operator or agent of same, of <br />the property located et the above site address hereby authorize the release of any end ell results, geotechnical data and/or <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it Is available and at the same time it is provided to me or my representative. <br />Nature of Service Request: <br />Assigned to <br />Enployee # U5Z / <br />Service Code <br />�Z? <br />'/ 2.73 <br />IDate Service Caipleted _/ / Further Action Required: Y / N I PROGRAM ELEMENT 7 7� 7'J ' <br />Fee Amount Amount Paid Date <br />-- k <br />RENS / / SUPV _/_/_ ACCT _/ / UNIT CLK /�_ <br />of Payment <br />Payment Type <br />Receipt k <br />Check # <br />Recvd By <br />-- k <br />RENS / / SUPV _/_/_ ACCT _/ / UNIT CLK /�_ <br />