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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> S0 Lop <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Holliday Inn Express <br /> SITE ADDRESS <br /> 3751 N Tracy Blvd . Tracy 95304 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT, <br /> Burkett's Pool Plastering 209 624-2921 <br /> HOME or MAILING ADDRESS FAX # <br /> 600 N . Frontage Rd . ( ) <br /> CITY Ripon STATE CA ZIP 95366 <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 QQFEDDERAL law's , <br /> s <br /> APPLICANT ' S SIGNATURE : C�tk4.m Y 1 LQA.D"m DATE : 6/4/2019 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER 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 Ime it is <br /> provided to me or my representative , <br /> ��� �' <br /> TYPE OF SERVICE REQUESTED : Pool and Spa Drain Cover ReplacmentIt A <br /> COMMENTS : %J UIV <br /> S <br /> AN d0 <br /> 4 <br /> QU1tV Cou <br /> I <br /> H�ITy DfFP N1Y <br /> FNT <br /> AM <br /> ACCEPTED BY: EMPLOYEE # : DATE : <br /> ASSIGNED TO : EMPLOYEE # : v � DATE : <br /> 20 <br /> 0 d==� 4 't" I <br /> Date Service Comp ted ( if already c pleted) : SERVICE CODE : P E : 27 <br /> Fee Amount: `2 1� O U Amount Pat 30 Z Payment Date l' 26 <br /> Payment Type ! Invoice # Check # 227 22 Y3 Recei ed By : , <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />