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SAN JOAgUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Refuse Collection and Admin FA 0001434 5 00(4It?6D <br /> OWNER/OPERATOR <br /> CHECK ifBILLING ADDREss❑ <br /> San Joaquin County Dept. of Public Works <br /> -FAcuw NAME <br /> Lovelace Materials Recovery Facility and Transfer Station <br /> SITE ADDRESS Manteca 95336 <br /> 2323 East Lovelace Road <br /> Street Number DIMI108 sheet name C& Mg Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 1810East Hazelton Avenue <br /> Public Works/Solid Waste sveetNumter 'tnWName <br /> CITY STATE zip <br /> Stockton CA. 95205 <br /> PHONE A EXT. APN# LAND USE APPLICATION# <br /> (209 ) 468-3066 001-100-88 UP-93-2 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( 205 468-3000 MOW <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Annette Borges, Integrated Waste Manager CHECK if BILLING ADDRESS® <br /> BUS N S NAME PHONE# EXT. <br /> Pub c Works, Solid Waste Division 209 468-3066 <br /> HOME or MAILING ADDRESS FAX# <br /> GPS 0. Box 1810 (209) 468-3078 <br /> �5t�ockton SIT. 9520IZ—T810 <br /> B UNG ACKNOWLEDGEMENT: l; 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 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 JOAQuiN <br /> COUNTY Ordinance Codes,Standards T TE and FEDERAL laws. <br /> APPLICANT'S SEGNATURE: DATE: // 0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER Ona AUTHORIzEDAGENT® Integrated Waste Manager <br /> If APPLICANTis not the BILLING 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 arty and all t tuts, g ttechtti,41 data attdfat mvironmerp,I/site assessment <br /> information to the SAN JOAQUIN COUNTY EWRONMENTAL 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 /> Solid Waste Plan Review — $465.00 <br /> ACCEPTED BY: EMPLOYEE#: DATE: G �' <br /> ASSIGNED TO: V EMPLOYEE#: j DATE <br /> Date Service CWmpleted (if already completed): SERVICE CODE: S P I E: Yy d 5— <br /> Fee Amount Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />