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I SAN JOAQUi4 COUNTY ENVIRONMENTAL HEALT . LARTMENT SERVICE REQUEST 10/? n y q 00 L5 Type of Business or Property �t4 (fj l ACI IT ID # i SERVICE REQUEST # Station 39 -AA -00 F81Transfer 7,309a OWNER/OPERATOR San Joaquin County, Department of Public Works CHECK if BILLING ADDRESS❑ FACILITY NAME Lovelace Transfer Station SITEADDRESS 2323E Date Service Completed (if already completed): Lovelace Road Manteca 95336 Street Number Direction Street Name cityZip Code HOME or MAILING ADDRESS (If Different from Site Address) 1810E. Hazelton Avenue Street Number Street Name CITY Stockton STATE CA ZIP 95205 PHONE #1 EXT. APN # LAND USE APPLICATION # ( 209) 468-3066 1204-070-05/204-060-20 up -93-0002 PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) 3 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Taj M. Bahadori CHECK if BILLINGADDRESSE] BUSINESS NAME San Joaquin County, Department of Public Works PHONE# EXT. (209) 468-3066 HOME or MAILING ADDRESS 1810 E. Hazelton Avenue FAx # (209)468-3078 CITY Stockton STATE CA Zip 95205 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, ST�FE RAL 1 ws.. / � APPLICANT'S SIGNATURE: 6 DATE: Z PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ®Senior Civil Engineer If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OFSERVICE REQUESTED: Permit modification of Lovelace Transfer Station COMMENTS: Modify refuse reciept hours to 6:30 am to 5 pm 7 days/ week. Begin green waste processing at the designated area per the EIR (South East of the scale house) ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: ; ' -� � �.� EMPLOYEE #: Y6 e,9,0 DATE: 9/ `///— Date Service Completed (if already completed): SERVICE CODE: Spl PIE: Y ya I Fee Amount: -1 6 j"U _ A--�' Amount Paid Payment Date 9&115 Payment Type 155r r Invoice # Check # Received By: E H D 48-02-025!v 0 SR FORM (Golden Rod) REVISED 11/17/2003