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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Refuse Collection and Admin FA 0001434 ����� <br /> OWNER i OPERATOR <br /> San Joaquin County Dept. of Public Works <br /> CHECKrfBiLLINGADDREss❑ <br /> fACIUrY NAME <br /> Lovelace Materials Recovery Facility and Transfer Station <br /> SfTE ADDREss <br /> 2323 East Lovelace Road Manteca 95336 <br /> Street Number Direction IMName C& Zip Cade <br /> HOME or MALxG ADDRESS (ff Different from Sfte Address) 1810 East HazEIeon-Avenue <br /> Public Works/Solid Waste Street Number Street Name <br /> CITY STATE ZIP <br /> Stockton CA. 95205 <br /> PHONE#1 ExT• APN# LANo USE APPLICATION# <br /> (209 ) 468-3066 001-100-88 UP-93-2 <br /> PHONE#2 ExT• SOS DISTRICTLOCATI�1 CODE <br /> ( 205 468-3000 MOW <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK ifBILLING ADDRESSO <br /> Annette Borges, Integrated Waste Manager <br /> BUSINESS NAME PHONE 9 En. <br /> Public Works, Solid Waste Division 209) 468-3066 <br /> HOME or MAILING ADDRESS FAX# <br /> P. 0. Box 1810 (209) 468-3078 <br /> Stockton 95201 $10 <br /> BELLING ACKNOWLEDGEM,EIYT: i; the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge dim all site and/or project specific EmuoNMENTAL t1EAl:.TH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this ation and that the work to be performed will,be dofie in accordance with all SAN IoAQum <br /> !COUNTY Ordinance Codes,Standards T TE and FEDE laws. <br /> APPLICANT'S-StGNATURE: HATE: D <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OT4 AUTIIORIzEDAGENT® Integrated Waste Manager <br /> If APPLICANT is not Ike BILLING PARTY,proof ofauthorization to sign is required 71rte <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby 41006M the release of any and a#F results, g teehnira( data aMW enviromrtental/site assessment <br /> information to the SAN 3oAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the salve time it is <br /> provided to me or my representative. <br /> TYPE OF SERE REQUESTED: <br /> Solid Waste Plan Review - $465.00 ✓ <br /> NVtRo�� RVQ ES <br /> ACCEPTED BY: EMPLOYEE M DATE. (' <br /> ASSIGNED TO: r ` ` EMPLOYEE#: j DATE: J <br /> Date Service C plated (if already completed): SERVICE CODE: s' 5— r P I E: Yy U 5- <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# I Check# Received By: <br />