Laserfiche WebLink
SAN JOAQuwouNTY ENVIRONMENTAL HEALTI PARTMENT <br />1 <br />Type of Business or Property <br />FACILITY ID # <br />RE EST # <br />Municipal Solid Waste Disposal <br />C E I VE D <br />APR 0 2 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />�RVICE <br />C O <br />OWNER/ OPERATOR <br />Forward, Inc. <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />ASSIGNED TO: <br />Forward Landfill <br />939-9111 <br />SITE ADDRESS gggg <br />South <br />FAx # <br />Austin Road <br />Manteca <br />95336 <br />Street Number <br />Dh <br />CITY St. Charles <br />Street Name <br />city <br />M12 Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br /># <br />Check # <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT• <br />APN # <br />LAND USE APPLICATION # <br />( 209) 982-4298 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />PAYMEN <br />X <br />Ward Herst <br />C E I VE D <br />APR 0 2 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# <br />EXT. <br />Herst & Associates, Inc. <br />ASSIGNED TO: <br />636 <br />939-9111 <br />HOME or MAILING ADDRESS <br />DATE: Z <br />FAx # <br />4630 South Highway 94 -North Outer Road <br />P 1 E: <br />( 636) <br />939-9757 <br />CITY St. Charles <br />STATE Missouri <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: 3!31/2009 <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Managing Director <br />IfAPPLiCANT is not the BILGING 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: <br />PAYMEN <br />COMMENTS: <br />C E I VE D <br />APR 0 2 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:j i <br />�, !!R <br />u A L <br />iy�/i" <br />EMPLOYEE M j75 <br />t <br />DATE: <br />Z <br />ASSIGNED TO: <br />L �L _ <br />EMPLOYEE M <br />DATE: Z <br />Date Service Completed (if already completed): <br />SERVICE CODE: D <br />P 1 E: <br />Fee Amount: <br />8® <br />Amount Paid <br />— <br />Payment Dateq ( <br />Payment TypeInvoice <br /># <br />Check # <br />Received By: ilo <br />EHD 48-02-025 SR FORM (Golden Rad) <br />REVISED 11/17/2003 <br />