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1.131 1 : 32 - 1 133 · 1 3'4 <br />SAN JOAQUii� LOUNTY ENVIRONMENTAL HEALTffu.ti:PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Single Family Residential <br />OWNER/ OPERATOR OAKWOOD LT VENTURES II, LLC <br />FACILITY NAME <br />FACILITY ID# <br />SITE ADDREss No address listed fo parcel APN 241-540-16 <br />Street Number Direction Street Name <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY <br />PHONE#1 355-1305 (925 ) <br />PHONE#2 <br />( ) <br />EXT. <br />EXT. <br />2000 Street Number <br />APN# <br />241-520-16 <br />SERVICE REQUEST# aot?J, 3 <br />CHECK if BILLING ADDRESS □ <br />Cit Zi Code <br />Crow Canyg,;:1if��e, Suite 350 <br />STATE ZIP <br />LAND USE APPLICATION# <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS Q <br />Bus1�Ess NAMESame as above PHONE# EXT. <br />( ) Same as Above <br />HOME or MAILING ADDRESS FAX# Same as above ( ) <br />CITY· STATE ZIP ,. <br />BILLING ACKNOWLEDGEMENT: I, the unders{gned property or business owner, operator or authorized agent of same,ackn6wledge that all site and/or project specific E+ONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or ac.tivity.will be billed to me or m� busi�e�.�}:� it�ntified on this fa�.: .... · . . <br />I also certify that I have prepared this appl.ic'Jr(�t�nd that the worl�.Jo'oe perfmmed will be done m accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S,TA'FE/l�a FEDERAL la -s� / I '/ APPLICANT'S SIGNATURE: ,,/ / /;/ DATE: C � Jo --·2.o ·2_ l . <br />PROPERTY I Bus1NEss OWNER □ J/ 0�i'RA OR I MANAGER D OTHER AUTHORIZED AGENT t;(, Se.,(� 12 ,- \) i. Ce f le !> ,:c.Q.Q.;;}--lf APPLICANT is not thf BILLING PARTY. proof of authorization to sign is required Title l·AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the abov,e site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN"€0UNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and.Jl_t the same tim� it is provided to me or my representative. f-PJtl },-1 ,.!"->. <br />TYPE,oF SERVICE REQUESTED: Surface and Subsurface Contamination Report <br />COMMENTS: <br />ACCEPTED BY: <br />ASSIGNED TO: <br />(if already completed): <br />Fee Amount: $304.00 Amount Paid <br />Payment Type <br />EHD 48-02-025 REVISED 11/17/2003 <br />Invoice# <br />EMPLOYEE#: <br />)., <br />EMPLOYEE#: <br />SERVICE CODE: 523 <br />Payment Date <br />Check# <br />SR FORM (Golden Rod)