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SAN JOAQUI �,OUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Municipal Solid Waste Disposal <br />) <br />R 00 655q7 <br />v <br />OWNER / OPERATOR <br />SEP 3 0 2008 <br />CHECK If BILL LING ADDRESS <br />Forward Incorporated <br />Hersl & Associates, Inc. <br />FACILITY NAME <br />939-9111 <br />HOME or MAILING ADDRESS <br />Forward Landfill <br />FAX # <br />SITE ADDRESS <br />South <br />Austin Road <br />939-9757 <br />Manteca <br />STATE MO <br />95336 <br />9999 Street Number <br />Direction <br />EMPLOYEE #: % <br />/ <br />Street Name <br />Date Service Completed (if already completed): <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />PIE: <br />Fee Amount: S' ° <br />Amount Paid <br />r <br />Street Number <br />C <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />( 209 ) 9824298 <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT <br />LOCATION ODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />121 <br />Ward Herat <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />SEP 3 0 2008 <br />PHONE # <br />ExT. <br />Hersl & Associates, Inc. <br />636 <br />939-9111 <br />HOME or MAILING ADDRESS <br />SAN JOAQUIN COUNTY <br />FAX # <br />4630 South Hwy 94 - North Outer Road <br />( 636 ) <br />939-9757 <br />CITY Saint Charles <br />STATE MO <br />ZIP 63304 <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. <br />APPLICANT'S SIGNATURE:DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT.0 d�— <br />If APPLICAn T is not the BILL/NG PARTY, proof of authorization to sign is required tt e <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 />r1 w . <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />TYPE OF SERVICE REQUESTED:IRECEIVED <br />COMMENTS: Foctr 9r0LLrl,4vt)r ( M ir�h ' Weds Ih5ta04 s .�l/hW'-13 �, AMW-a 1, <br />1a0'--lyo`OtIp llsor- <br />SEP 3 0 2008 <br />AMvi-.aa/ a44 AA4VV-.23• Pn le, ,d cov,,en' <br />9r6,%*. <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: % <br />/ <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE`: <br />PIE: <br />Fee Amount: S' ° <br />Amount Paid <br />r <br />I Payment Date <br />C <br />3 b 08 <br />Payment Type \/ <br />Invoice # <br />Check # 1 S L ? S <br />I Received By: _ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />