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.00 <br />SAN JOAQUY COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Review <br />PAYME <br />FACILITY ID # <br />SERVICE REQUEST # <br />Solid Waste Facility <br />SAN JOAQUIN COUNTY <br />ENTA <br />-75 <br />l �, _% <br />OWNER / OPERATOR <br />EMPLOYEE #: V t) <br />If BILLING ADDRESS <br />Tracy Material Recovery & Transfer <br />Station, Inc. CHECK <br />FACILITY NAME <br />Tracy Material Recovery <br />& Transfer <br />Station <br />SITE ADDRESS 30703S. <br />MacArthur <br />Drive <br />Tracy <br />95377 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />Payment Type <br />Invoice # <br />Check # -;Lq -7-73 <br />Received By: <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CIT. <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(209)835-0601 <br />253-130-19 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR L n <br />F D 6 n CHECK if BILLING ADDRESS <br />BUSINESS NAME ��'�L— PHONE# EXT' <br />HOME or MAILING ADDRESS FAX # <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />0�j acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />y�c ,o ivity will be billed to me or my business as identified on this form. <br />¢, Wcertify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />C Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS ONV NER® OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLic NT 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: Solid waste Permit <br />Review <br />PAYME <br />COMMENTS: <br />OCT 2 6 2011 <br />SAN JOAQUIN COUNTY <br />ENTA <br />HEAI-TH DE ARTMENT <br />ACCEPTED BY: 0 C, t <br />EMPLOYEE #: V t) <br />DATE: <br />ASSIGNED TO: dL a—r N 1 <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: .� <br />P I E: <br />" TT ��J <br />FeeAmount:., <br />Amount Paid <br />SI <br />Payment Type <br />Invoice # <br />Check # -;Lq -7-73 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />