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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Industrial Warehouses PA-1900208V <br /> yt <br /> qK. <br /> OWNER/OPERATOR LBA Realty - LBA Logistics V� El <br /> If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 14800 W. Schulte Road FTracy 95377 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3347 Michelson <br /> Street Number Street Name <br /> CITY Irvine STATE CA ZIP 92612 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 949) 664-2093 209-240-230-000 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( 949)757-2322 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Brett Crews & Glen Andersonx0 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Schaaf& Wheeler PHONE# EXT. <br /> 408 246-4848 <br /> HOME or MAILING ADDRESS 1171 Homestead Rd., Ste. 255 FAx# <br /> CITY Santa Clara STATE CA ZIP 95050 <br /> BILLING ACKNOWLEDGEMENT: 1, 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: 12/7/2020 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Engineer <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. WMENT1 <br /> TYPE OF SERVICE REQUESTED: �S N L J f e v l e <br /> , RECEIVED <br /> COMMENTS: <br /> DEC 0 9 2020 <br /> SAW JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 1 EMPLOYEE#: DATE: * 00p <br /> a�d(� <br /> � r <br /> ASSIGNED TO: S EMPLOYEE#: DATE: �� �P a-b <br /> Date Service Completed (if already completed): SERVICE CODE: 5a3 P i E. AW <br /> Fee Amount: �� Amount Paid egg Payment Date <br /> Payment TypeAA)c Invoice# Check tori 7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />