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SAN JOAQUIN COUNTY EwmoNMENTAL HEALTH DEPARTMENT <br /> -0 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Dermagraphies \ _ <br /> OWNER/OPERATOR <br /> Davnci Maximus CmrcK ff <br /> FACUN NAME Maximus Dermagraphix <br /> SiTEADDRESS 624 Central Avenue Tracy 95376 <br /> Strut Numb-, I Dimado Sbut N ms C' Zip cad* <br /> NOME or MAun ADDRESS (M Different from Sib Addross) 4695 Windsong Court <br /> Strut Numbe <br /> T aywiftme <br /> Cmr Tracy STATE CA ZIP 95377 <br /> PONE 111 EXT. APN* LAM USE APPUCAnAN# <br /> ( 209 ) 640-8411 <br /> PHONE#2 EXT. BOS DisTmoT LocAT;oN CoDE <br /> ( ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR Davuci Maximus Cwrwif BiLuNGADDnesslJ <br /> BUSINESS NAME MaximusDagraphix PNONEtk <br /> tnmExT <br /> 209L 640.5411 <br /> HOME or MAuNG ADOREss FAX d <br /> 624 Central Ave <br /> CITY Tracy STATE CA TIP 95376 <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property or business owner,operator or authorized agent of same, <br /> acknowledge that all site and/or project specific EwRoNMENTAL 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 JoAQurN <br /> COUNTY Ordinance Codes,Standards,STd FEDERAL laws. <br /> 7 <br /> APPLICANT'S SIGNATURE: DAA; 07/20/17 <br /> PROPERTY t BUsnvFSS OWNERM OPERATOR t MANAGER 0 �O'TEW&RAA RMZ A Grp Manager <br /> IfAppmcANT is not the Bium 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 ENvutoNMENTAL 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 REQUESM Consultation RE ENT <br /> COMMENTS: Al <br /> 201? <br /> eNv�AQW�ti'c <br /> 4`�i r},R FtibM�p,,�VNTy <br /> d. <br /> ACCEPTED BY: C EMPLOYEE# 573 IDAm Z /' <br /> ASSIGNED TO: U EMPLOYEE#: Gja � DATE: 2 <br /> Date Service Completed (it already completed): SEIMCE CODE: D� P t E <br /> Fee Amount: S d Amount Paid /75I Payment Date <br /> Payment Type �rQ� Involce# C ReceivedBy: <br /> EHD 48 02 025 SR FORM(Golden Rod) <br /> RE\nSED 11117/2003 <br /> t <br /> ZA <br />