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013PA13PA21oog33 0 01 3 <br /> SAN JOAQ UIIN COUNTY ENVIRONMENTAL HEALTH ii -EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Single Family Residential 3 & 3 <br /> OWNER / OPERATOR ElUUUU <br /> OAKWOOD LT VENTURES II , LLC CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS No address listed fo parcel APN 241 - 540 - 16 <br /> Street Number Direction Street Name City Zin Code <br /> HOME Or MAILING ADDRESS ( If Different from Site Address ) <br /> 2000 Street Number Crow CanygFrLgJgpe , Suite 350 <br /> CITY STATE ZIP <br /> San Ramon CA 94583 <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> (925 ) 355 - 1305 241 -520 - 16 <br /> PHONE #2 .� En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQ.UESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE # Exr • <br /> Same as above Same as Above <br /> HOME or MAILING ADDRESS FAX # <br /> Same as above ( ) <br /> CITY STATE ZIP <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 EN�IItONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business, s i �ntified on this form . <br /> I also certifythat I have prepared this app lic ti. and that the work tore p erformed will be done in accordance with all SAN JOA UIN <br /> p p : � p Q <br /> COUNTY Ordinance Codes , Standard , STATE/I d FEDERAL la <br /> ;r` f "/ <br /> APPLICANT ' S SIGNATURE : ;' ,!� � r/ ;' DATE : "Firi- lo L <br /> r, <br /> PROPERTY / BUSINESS OWNER ❑ ✓ ' OO PERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT �� ,���e cn " L �� ;� S • c %l �t <br /> If APPLICANT is not thIBILLINGPARTY, proof of authorization to sign is required IIJ Title <br /> L <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 VOUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and t the same time it is <br /> provided to me or my representative . <br /> N ' <br /> TYPE OF SERVICE REQUESTED : Surface and Subsurface Contamination Report 's <br /> COMMENTS : (104 Scipio e i47 ( 610 <br /> 21 <br /> SAN <br /> V � <br /> /� QU/lv co <br /> Pr ,llI <br /> RTAjENT <br /> ACCEPTED BYIF <br /> . EMPLOYEE # : DATE : <br /> ASSIGNED TO : A EMPLOYEE # : DATE : <br /> IC1� r <br /> Date Service Completed ( if already completed ) : son SERVICE CODE : 523 P E 2603 <br /> Fee Amount : $ 304 . 00 Amount Paid Payment Date <br /> Payment Type Invoice # Check # 1 Received By : <br /> EHD 48 -02-025 SR FORM (Golden Rod ) <br /> REVISED 11 / 17/2003 <br />