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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Hotel 12 0 (c' SIOD001 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> CNI THL SMB, LLC <br /> FACILITY NAME <br /> Fairfield Inn &Suites <br /> SITE ADDRESS 2410 Naglee Road Tracy T95376 <br /> Street Number DirectionStreet Name C ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 404) 918-7188 212-050-630-000 <br /> PHONE#2 ExT• BOS DISTRICT--7LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Daniel Savage CHECK If BILLING ADDRESS 21 <br /> BUSINESS NAME CNI THL SMB,LLC PHONE# EXT. <br /> 404 )918-7188 <br /> HOME or MAILING ADDRESS FAX# <br /> 6011 CONNECTION DR ( ) <br /> CITY IRVING STATE TX ZIP 75039 <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 /> APPLICANT'S SIGNATURE: DATE: 04/08/2019 <br /> PROPERTY/BUSINESS OWNER[] OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El Permitting Agent <br /> If APPLIc.4NT is not the BILLING PARTY.proof of authorization to sign is required Time <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 the same time it is <br /> provided to me or Iny representative. <br /> TYPE OF SERVICE REQUESTED: OVL(;Z }C t �.�L� la-la--tPAY <br /> COMMENTS: � i Z CSI .,., \ t IJI El��'v—P® <br /> Q�"Ik APR 12 2019 <br /> SM ENVIRON CQUNTM <br /> HEALT � MENTgL <br /> ACCEPTED BY: —III 11�w <br /> { EMPLOYEE#: DATE: i l <br /> ASSIGNED TO: Ll EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid _ Payment Date 2' <br /> Payment Type Invoice# Check# I-?3 _ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />