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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Adam Burton <br />BUSINESS NAME <br />FACILITY ID # <br />Costera Waste & Envirommnetal, Inc. <br />SERVICE REQUESTT�# <br />L <br />FA000 <br />j 1;j� <br />2 <br />( ) <br />®� Ra'9q <br />Commercial Development <br />10 2021 <br />OWNER / OPERATOR <br />DEPART <br />RrMAL <br />FN <br />Holly Commerce Center LLC <br />�I �/ <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />DATE: <br />5/1C) UJ <br />Holly Commerce Center, LLC <br />ASSIGNED TO: <br />SITE ADDRESS 20500 <br />Holly Drive <br />I <br />EMPLOYEE#: <br />DATE: C) Z� <br />Tracy <br />(if already completed): <br />95304 <br />Street Number <br />Direction <br />P 1 E: 2 �� <br />Street Name <br />0! 12 u <br />t' <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Date <br />Payment Type <br />it Jc <br />Lafayette Circle <br />Invoice # <br />21 <br />Street <br />Number <br />Received By: 6& <br />Street Name <br />CITY <br />STATE <br />ZIP <br />Lafayette <br />CA <br />94549 <br />PHONE #1 EXT• <br />APN #LAND <br />USE APPLICATION <br /># <br />( 925) 283-8777 <br />L <br />.2 k <br />O <br />N/A <br />PHONE#2 EXT• <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />Adam Burton <br />BUSINESS NAME <br />PHONE# EXT• <br />Costera Waste & Envirommnetal, Inc. <br />( 415 533�O 112 <br />HOME or MAILING ADDRESS <br />FAX# <br />14 EI Vaquero <br />( ) <br />CITY Rancho Santa Margarita STATE CA ZIP 92688 <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; 5/10/21 <br />v <br />PROPERTY /BUSINESS OWNER 1:1 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 14 Contractor <br />1i APPLICANT is not the BILLING PART)', 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. ` 0A 1 <br />TYPE OF SERVICE REQUESTED: I✓ l `1 I �/ 62S `.�I:Lvoo <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />COMMENTS: <br />D <br />MAY <br />10 2021 <br />SAN ,l <br />QUI co <br />i HE LTH AENTU ry <br />DEPART <br />RrMAL <br />FN <br />ACCEPTED BY: <br />�I �/ <br />EMPLOYEE #: <br />DATE: <br />5/1C) UJ <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: C) Z� <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE: a <br />/3 <br />P 1 E: 2 �� <br />Fee Amount: <br />0! 12 u <br />t' <br />Amount <br />Pai [ �o�. �� <br />Payment <br />Date <br />Payment Type <br />it Jc <br />Invoice # <br />Check # )2.4=2 <br />Received By: 6& <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />