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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> r <br /> ` SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# _ SERVICE REQUEST# <br /> OWNER/OPERATOR Shea Homes, Limited Partnership CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Bergamo Residential Tract 3964 <br /> SITE ADDRESS <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2630 Shea Center Drive Street Number Street Name <br /> CITY Livermore STATE CA ZIP 94551 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (925 ) 245-3631 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (925 ) 525-0162 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR David Best <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Shea Homes Limited Partnership PHONE# EXT. <br /> 25 245-3631 <br /> HOME or MAILING ADDRESS 2630 Shea Center Drive FAx# <br /> CITY Livermore STATE CA ZIP 94551 <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 /> APP'LICANT'S SIGNATURE: paw-dA i?"t- DATE: 9/23/2020 <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Authorized Agent <br /> IfAPPLICANT 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 ,ts me time it is <br /> provided to me or my representative. -1 M <br /> TYPE OF SERVICE REQUESTED:Phase 1 ESA review for residential subdivision AVE <br /> COMMENTS: <br /> SAN P 23 ZO20 <br /> HEgJOA tj1N <br /> L p qR rA�TY <br /> MENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: - O Amount Paid 3(� ,(�� Payment Date '?12-312-C? <br /> Payment Type Vi 5a-- Invoice# Check# 047 l '�b I <br /> Received By: <br /> — i�—] <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />