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SAN JOAQ OUNTY ENVIRONMENTAL HEA EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Transfer/Processing/Composting Facility �A��� I�p �!5p G'K) &a 4, c.7 <br /> OWNER/OPERATOR <br /> Forward Inc . CHECK if BILLING ADDRESSE] <br /> FACIUTYNAME Forward Resource Recovery Facility <br /> SITE ADDRESS 9999 S . Austin Road Manteca 95336 <br /> Street Number I 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 /> (209)982-4298 E.Fanning 01-060-03 (per SWFP) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR John Boucher CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAMEPHONE# EXT. <br /> SWT Engineering (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 a d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPOR/MANAGER ❑ OTHER AUTHORIZED AGENT Principal Planner <br /> If APPLICANT is not the BI ,/NG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: '4 Y* <br /> COMMENTS: VFX <br /> '%%'o ?014 <br /> H� De FNp UMY <br /> ACCEPTED BY: Been Cscot+o EMPLOYEE#: 2(Dl,a DATE: s/,,,/I4 <br /> (� , <br /> ASSIGNED TO: ) SCS LOtEa EMPLOYEE#: .1001a, DATE: 5/.,1I14 <br /> Date Service Completed (if already completed): SERVICE CODE: S'"I PIE: �d 5 <br /> Fee Amount: -k�a5 Amount Paid &a s;d b Payment Date 5 V1 <br /> Payment Type LZ Invoice# Check# Received B <br /> y <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />