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SAN JOAQUUNTY ENVIRONMENTAL HEAL PARTMENT <br />it SERVICE REQUEST <br />Type of Business or Property <br />Transfer/Processing/Composting Facility <br />FACILITY ID # <br />F A Cyo V (�o , <br />BUSINESS NAMEPHONE# <br />SWT Engineering <br />SERVICE REQUEST # <br />S400 697 3 3 <br />OWNER /OPERATOR <br />Forward Inc. <br />CHECK if BILLING ADDRESS E] <br />FACILITYNAME Forward Resource Recovery <br />Facility <br />SITE ADDRESS 9999S <br />Street Number <br />S. I <br />Direction <br />Austin Road <br />Street Name <br />Manteca <br />95336 <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />TCi <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />(209)982-4298 E. Fanning <br />APN # LAND USE APPLICATION # <br />01-060-03 (per SWFP) <br />PHONE#2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR John Boucher <br />CHECK If BILLING ADDRESS ❑ <br />BUSINESS NAMEPHONE# <br />SWT Engineering <br />COMMENTS: <br />EXT. <br />(909)390-1328 <br />HOME or MAILING ADDRESS 800-C South Rochester Avenue <br />FAX# <br />DATE: I JJ 2,0 D 1 s <br />ASSIGNED TO: <br />(909)390-3848 <br />CITY Ontario <br />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. 7 <br />APPLICANT'S SIGNATURE: � DATE: l a? 3 <br />PROPERTY/ BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® Principal Planner <br />IfAPPLiCANT is not i �el ILLINGPARTY, 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: <br />COMMENTS: <br />ACCEPTED BY: <br />V e, r, E J (o O <br />EMPLOYEE #: 'Q as <br />DATE: I JJ 2,0 D 1 s <br />ASSIGNED TO: <br />&n —S t U �fv <br />EMPLOYEE #: E61 L <br />DATE: j,I3D /13 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: (4b1 CtS <br />Fee Amount: <br />62S-1 <br />Amount Pai to �� <br />Payment Date <br />1 31 `3 <br />Payment Type <br />, Sw <br />Invoice # <br />�/ , 09��5 S <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />