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e N 0 � <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LLQ PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />PHONE# ExT. <br />(209) 468-3066 <br />IF-AOtO1g3y � <br />n 9 <br />Transfer Station <br />39 -AA -0008 <br />CITY Stockton STATE CA ZIP 95205 <br />OWNER/ OPERATOR San Joaquin County, Department of Public Works <br />EMPLOYEE M <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME Lovelace Transfer Station <br />SITE ADDRESS 2323E <br />Lovelace Road <br />Manteca <br />Amount Paid <br />95336 <br />Street Number <br />ction <br />Street Name <br />Invoice # <br />Check # <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 1810 <br />E. Hazelton Avenue <br />I <br />Street Number <br />Street Name <br />CITY Stockton STATE CA ZIP <br />95205 <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />( 209) 468-3066 1204-070-05/204-060-20 <br />up -93-0002 <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />3 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Taj M. Bahadori CHECK If BILLING ADDRESS 0 <br />BUSINESS NAME <br />San Joaquin County, Department of Public Works <br />PHONE# ExT. <br />(209) 468-3066 <br />HOME or MAILING ADDRESS <br />FAX # <br />1810 E. Hazelton Avenue <br />(909)468-3078 <br />CITY Stockton STATE CA ZIP 95205 <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 la s. <br />APPLICANT'S SIGNATURE: ✓� , DATE: Z / Z4- <br />PROPERTY/BUSINESS OWNER❑ OF41RATOR/MANAGER ❑ OTHERAUTHORIZED AGENT ®Senior Civil Enqineer <br />If APPLICANT is not the B/LLING 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: Permit review of Lovelace Transfer Station <br />COMMENTS: ypf r4v- ,Q <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: „�i¢ %�%)`, i4 3-0 �� �i� <br />EMPLOYEE M <br />DATE: -2,/.A 7//,r <br />Date Service Completed (if already completed): <br />SERVICE CODE: 5 mss'' <br />P I E: L14CS <br />Fee Amount: .Q f) <br />Amount Paid <br />�� — <br />Payment Date <br />314 /i <br />Payment Type S'S 7- <br />Invoice # <br />Check # <br />Received By: L16 <br />EHD 48-02-025 L?0 12D SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />