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SAN JOAQUIN&LINTY ENVIRONMENTAL HEALTH 0PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �51 3 <br /> OWNER/OPERATOR �N� <br /> USA Waste of California, Inc. dba, Central Valley Waste SelFUTERLLINGADDRES3❑ <br /> FACILITY NAM <br /> Centra Valley Waste Services <br /> SITE ADDRESS E Turner Road Lodi 95241 <br /> 1333 Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P.O. Box 241001 Street Number Street Name <br /> Lodi STATE 2195241 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (209) 369-8274 04933002 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Brian Waters CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME Central Valley Waste Services PHONE# EXT• <br /> (209) 333-5611 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 241001 ( 209) 369-6894 <br /> CITY Lodi STATE CA 21P 95241 <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 EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 3�/ .201E <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is 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 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 � N� 0 <br /> COMMENTS: RE 03 <br /> aOAQUfN ESS PLyS <br /> HFyITN� <br /> ACCEPTED BY: r�- __ _ e EMPLOYEE#:-0 DATE: /I/ <br /> ASSIGNED TO: EMPLOYEE#: DATE: 'C <br /> Date Service Completed (if already completed): SERVICE CODE: �7/ P/E: <br /> Fee Amount: 6 Amount Paid Payment Date 3 �y <br /> Payment Type ✓ Invoice# Check# O p 103 i�-j 1,5Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />