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r:�'�'��!'"".-sm" o ;�....,,,�s rr'r�r.�:=���- 't' - .,.rye' :.. <.-' � -'fir..::;r.� ,. ,+�,.+.�x•4 , <br /> 1 <br /> is <br /> SAN JOAQU°IN Couxw:ENVIRONMENTAL HEALTH.DtP_ ARTMENT <br /> SERVICE REQUEST <br /> ^ Y <br /> Fl�C1LITY Ib# — SERVICE REQUEST,# <br /> Type of Business or Property <br /> bar. <br /> �i <br /> bar. addition to existing movi6.theatre �O l .� 1 v Ti <br /> OWNER./OPERATOR CHEcK ifHILLING ADDRESS <br /> American Multi.-Cinema, Inc <br /> F46wYNAME Showplace Manteca ',16 <br />` SiTf:An©IiEss :848 <br /> '" LifeSt Manteca 95337 <br /> '.. I � Zi Code <br /> 5treetNumber Olrectlan - - SereetNam <br /> HOME Ot MAILING.ADDRESS':(If Different from Site Address) 11500 Ash St <br /> '- - StreelNtrmhec=:.- - StrOe• ame' .. . <br /> STATE KS ZIP 66211 <br /> �`;GiT-'' Leawood <br /> PNOt 1 -- APN#. -LAND US! APPLICATION# <br /> 1819 44877331 <br /> PHONE N2 EXT. Bt35 t715TRIC7 LocATtoN COGS <br /> t ) - <br /> CO" NTRA&M! $ERVIGE REQUEST(QR <br /> REQUESTOR Samantha IgoU cxrcKifBILLING AoDRESS <br /> C� <br /> PHONE# EXT. <br /> $USINEssNAME ArcVision Inc 314 415-2400 _ 282 <br /> ROME or MAILING AUORESS =- � �FAX <br /> 1950 Crai .Rd' . Ste 300 <br /> 1314) 415-2300 " <br /> CITY,-St . Louis STATE MC ZIP 63146 <br /> BILLINGL ACKNOWLEDGEMENT: 1,athe-u.nderrsigned pr©perty or buslness,oWner;.operator ot,authorized agent of sarna, <br /> acknowledge that wall'site:andlor project specific ENVIRONMENTAL:.HEALTH DI:PARTtaeNT"hourly charges associated.with.this.project;ori <br /> activity will be billed'to-me or 6iy business as_idehtit'ied on this form. <br /> I.also certify that'1 have prepared this application and1hat the work to,be performed wail t5s done in accordance with all SAnt JOAaUIR. <br /> COUNTY Ordinance Codes;Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: . IJATr=: . <br /> PP16PERTY1BusiNEssOwNER"0 OPERATORI.MANAGER i..t O-rHeRAUTHORIZED AGENf 0 permit. .cobrdinator <br /> If APPLICANT is not tho BILLING PARTY proof of authorization.fo sign is-required ?Tyle " <br /> AUTHORIZATION TO'RELEASE INFORMATIONt When applicable, I,the owner or operator of the property located,at-:the above <br /> site address-,,hereby authorize the release of any and all results,geotechnical data.andtor environmental/site assessm6nt information. <br /> to the SAN Ji AQUIN COUNTY-ENVIRON MENTAL HEALTH DEPARTMENT as soon as It Is avallable and at the same time it Is',provlded tome or <br /> my represantative. - <br /> TYPE0FSERVICEREQUEST ED: add' bat into lobby of existing movie theatre <br /> COMMENTS: <br /> �wc <br /> ACCEPTED BY: PMQ ,.�.� _ t/ul Ut l [ O EMPI.OYIc)W#: DATE: 0I n 131/o <br /> �Y <br /> ft <br /> A85IGNEGTC: degant naff <br /> EMPLOYEt#: DATE: <br /> Date Service Comipleted'(If already caitsptetstt): SERVICE CODE: G rj�.�J„ ,,, •` <br /> Fee Amount. � !n Amount P O f ' <br /> �" 6 aid - Payrnent'Date 6 <br /> Payment TypG Involve# Check# Revolved BY. <br /> ... <br /> CC. <br /> EHO48-02-025 ry SR FORM(Golden ROO) <br /> 071E 7(68 <br /> sA. qt jCLJll�l <br /> . <br /> TMEW <br />