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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 Warehouse 5R 00 I I 15 <br /> OWNER/OPERATOR <br /> Holly Commerce Center, LLC CHECK If BILLING ADDRESSE] <br /> FACILITY NAME <br /> SITE ADDRESS 20500 South Holly Drive Tracy 95304 <br /> Street Number Direction Street Name Citv Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 21 Lafayette Circle Suite 200 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Lafayette CA 94549 <br /> PHONE#1 EXT. APN# Formerly 212-160-10 after LAND USE APPLICATION# <br /> ( 925 ) 283-8777 Lot Line Adjust.212-160-18 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> David Haugen CHECK If BILLING ADDRESS <br /> BUSINESS NAME Phelan-Haugen Development PHONE# ExT• <br /> 510 907-7898 <br /> HOME or MAILING ADDRESS FAX# <br /> 1999 Harrison Street,Ste 1816 ( ) <br /> CITY Oakland STATE CA ZIP 94612 <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 F L laws. <br /> APPLICANT'S SIGNATURE: DATE: Z-11 e3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑X Regional Partner <br /> IfAPPL/CANT 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available a 44 the same time it is <br /> provided to me resentative. rr <br /> 4MAREREQUESTED: Nitrate Loading Study Soil Suitability Study �V <br /> COMMENTS: <br /> MAY 2 3 7111 SA&II0 3 ,7 <br /> 018 <br /> y�� F <br /> q t <br /> [a\' 'IllO\)II•:\•I �1. Ill•: �1:1•II O '�ENTgUN�' <br /> N'F /a/&Vtr'? <br /> ACCEPTED BY: 4RP r EMPLOYEE#: ATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:7&1,2' <br /> Fee Amount: $608.00 Amount Paid Payment Date f z3 <br /> Payment Type L14 Invoice# Check# 1325 Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />