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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> Senior multi-family Residential <br /> OWNER/OPERATOR <br /> Reynolds Ranch Senior Development Co CHECK if BILLING ADDRESS <br /> FACILIrY NAME Revel Lodi <br /> SITEADDRESS 2923 Reynolds Ranch Parkway Lodi <br /> 95240 <br /> Street Number I Direction Street Name C w Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ---_ Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ) r <br /> PHONE#2 ExT• II SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Matt Hefner <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Katerra PHONE# ExT. <br /> 1916 541.9001 <br /> HOME or MAILING ADDRESS 9305 E.Via de Ventura,Suite 200 FAx# <br /> CITY Scottsdale STATE AZ ZIP 85258 <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 ENWRONmENT.AL 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: 0310712019 <br /> PROPERTY/BUSLm;ss OIA'NF:RM( OPERATOR/MANAGER ❑ OTHER AITHOR7ZED AGENT❑ <br /> IfAPPLICAAT is not the BLLLiwi PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 Cowry ENVIRONMENTAL HEALTH DEPARTNIF.NT as soon as it is available and at the s��tuiie it is <br /> provided to me or my representative. T <br /> TYPE OF SERVICE REQUESTED: <br /> IV, <br /> COMMENTS: AR <br /> S,yN <br /> 4u <br /> J <br /> N E�1RON/N COV <br /> FgLTyDEPAR A IY <br /> ACCEPTED BY: C(�'1�6 EMPLOYEE M DATE: 3 12- <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z_3 PIE: <br /> Fee Amount: - Amount P a IA15TS� �� Payment Date71 <br /> Payment Type __ Invoice# Check# 3_ 15 Z Reicelved By <br /> EHD 48-02-025 NSR FORM(Golden Rod) <br /> REVISED 11/17/2003 �� 1. •.� <br />