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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 SQ CO—tq <br /> OWNER/OPERATOR �\ <br /> Holly Commerce Center, LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 20500 South Holly Drive Tracy 95304 <br /> Street Number Direction Street Name city Zip 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#I APN# Formerly 212-160-10 after LAND USE APPLICATION# <br /> ( 925 ) 283-8777 Lot Line Adjust.-212-160-18 <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> David Haugen CHECK If BILLING ADDRESS <br /> BUSINESS NAME Phelan-Haugen Development PHONE# P"T <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 FPA—',RAL laws. <br /> APPLICANT'S SIGNATURE: p DATE: <br /> PROPERTY/BUsiNESs OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Regional Partner <br /> /f 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 ajthe same time it is <br /> provided to resentative. /r <br /> T E EgUESTED: Nitrate Loading Study Soil Suitability Study �V <br /> COMMENTS: 23 <br /> MAY 2 3 7111 <br /> �V�RQUINc 20j8 <br /> EN 'IRONNIEN" -ki- Ill; �I hII /FPgRTlgUyll <br /> DI•:I'AltoIL•:N'I' <br /> ACCEPTED BY: EMPLOYEE#: ATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E Z <br /> Fee Amount: $608.00 Amount Paid ,� Payment Date •.523 <br /> Payment Type( Invoice# Check# X32$ Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />