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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 0 (c' S9000 <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 95376 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Sheet 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 LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Daniel Savage CHECK If BILLING ADDRESS <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/BLTsmEss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT© Permitting Agent <br /> If APPLICANT is not the BILLING P.4RTY 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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: l\ PAY <br /> COMMENTS: i-e t _ �i �, l N ECE1Wo <br /> APR 12 2019 <br /> SM ENIflR01VM COU <br /> HEALT NMENTgi TY <br /> ACCEPTED BY: /`l rtr EMPLOYEE#: DATE: i I <br /> ASSIGNED TO: L,-k EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: <br /> Fee Amount: Orb Amount Paid Payment Date <br /> Payment Type Invoice# Check# ���3 _ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />