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SAN JOAQUI*UNTY ENVIRONMENTAL HEALTI*PARTMENT <br /> ��II SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Solid Waste Disposal ::I Site000(/� <br /> OWNER/OPERATOR I Y' <br /> Forward Inc . CHECK if BILLING ADDRESS El <br /> FACILITY NAME Forward Landfill <br /> SITE ADDRESS9999 S . Austin Road Manteca 95336 <br /> Street Number Direction 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#I ExT• FAPN# LAND USE APPLICATION# <br /> (209)982-4298 D.Litchfielde JTD Sec 2 . 2 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR John Boucher CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME SWT Engineering PHONE# ExT' <br /> (909) 390-1328 <br /> HOME orMAILINGADDRESS 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,ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:It DATE: y"y.W13 <br /> PROPERTY/BUSINESS OWNER /MANAGER ❑ OTHER AUTHORIZED AGENT0Principal Planner <br /> IfAPPL1CANT is not thJERATOR <br /> LL1NG 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 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: �� ,,f S cJ PAYMENT <br /> COMMENTS: V RECEIyED <br /> APR 16 2013 <br /> SAN JOAQUIN COUNTY <br /> -JOAQUIN <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M C DATE: <br /> ASSIGNED T0: EMPLOYEE#: U L DATE: 1-7 <br /> Date Service Competed (if already completed): SERVICE CODE: ZS P7 E: u S <br /> Fee Amount: 6 Amount Paid Payment Date <br /> Payment Type Invoice# Cht= "" a732�5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />