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❑ New Facility Hj Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Forward Landfill Inc. <br /> Site Address City State ZIP <br /> 9999 S Austin Road Manteca CA 95336 <br /> APN supervisor District <br /> 20106002 San Joaquin County <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel m Other <br /> Requested Operating Permit <br /> Comments <br /> 5-YR Permit Review Application <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> required <br /> ❑ Billing Party 10 Facility Owner ❑ Facility Contact 10 Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, Indicate type and license number <br /> Forward Landfill Inc. <br /> Address City State ZIP <br /> 9999 S Austin Road Manteca CA 95336 <br /> Phone Phone Email <br /> 209-235-9622 <br /> ❑ Billing Party ❑ Facility Owner ® Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, Indicate type and license number <br /> Osvaldo Cordero <br /> Address City State CA ZIP 95336 <br /> 9999 S Austin Road Manteca <br /> Phone Phone Email <br /> 209-601 -2274 ocordero@republir-service;.com <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor i1 <br /> First Name Last name If contractor, indicate type <br /> Address City State I�p / <br /> Phone Phone Email DD <br /> E �A4U1N C <br /> Q <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that al I <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as Identified on Nr <br /> form. <br /> I also certify that I have prepared this applicatl _ d that-the W".. te'perforined will-be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards, STATE and FEDERAL laws. <br /> ---_ <br /> APPLICANT'S SIGNATURE: _/_ —% DATE: 02/16/2026 <br /> ❑ PROPERTY/ BUSINESS OWNER L OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT Is not the BILLING PARTY, proof of authorization to sign Is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I,the owner or operator of the property located at the above site address, hereby authorize the <br /> release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as It Is available and at the same time It is provided to me or my representative. <br /> Accepted By Assigned To Linked FA ID <br /> Date PE Fee e d Numb, <br /> li a <br /> ❑ Cash ❑ Check k Confirmation H Payment'7 Received By <br /> Rev 07/10/2024 <br />