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<br /> ` °IISA�I :lOA4UW DUIV�T�-E'Nl1lRt3NMEN�'AL'HE/ALTH DEPARTME9VT
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<br /> n y� ! " fid'�9craG FACIL1Tlf 11�# _' Ll�l
<br /> i' SERVICE REQUEST#
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<br /> h ba='addition to existing'movi'eathe dll�r ;1u�1P. ,4 � 4 ;
<br /> .. :�,., Lr 7�nr r v qp rr „-j 3 Z" t•-F_ ; r i '�" '� , I r 1�
<br /> e 1 06AEiR OPERATOR t a
<br /> f y erl 0 4 i' CNECKifBILLiNGADDRESS© '
<br /> l•r it h !a a r �., 5 ! a 1'd�{-a , }-t�', 1 �, iY .T } -!
<br /> American' :Multi�Cnema,
<br /> •' :'� n s 5 t+.� lik i�lf t' �,+'w+t•. 1 j'-fr ,' ,v ,'11 I� ^_' r�
<br /> FACIIITYNAME- Showp'l'ace _Manteca 11,6 h ,,
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<br /> SITE ADDRESS $,48ry t ""Li� est;y'1e St`; ' ;`' I LNianteca +� * 19533,7
<br /> G r Ir. n ., n o
<br /> AstreetNumb?r olreetidn Y , 5rettN9' e z } 2i Code
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<br /> ' u f'•r,. - i p}Y;ty r ..q�
<br /> HOME DC MAILING ADi3TtE5$,(If DiHerenk from Site Adtlress a' -6W
<br /> 115rf
<br /> x.DF ✓t r
<br /> .'4 , ''.. _ Street Meme-_ rr.'. 3•' -
<br /> �' r �,:i' t t ; t /: a -tv` '-STA7E,'KS r, 7 ZIP
<br /> I :CITY Lea Wood
<br /> lAP{a# Is, sy r 1
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<br /> ..P..�ti
<br /> ^m -ExT I'�r , I a i'b i I } s LAND USE APPLICATION#
<br /> .PHONEY a
<br /> r N J
<br /> 7 FH F
<br /> x816. 44$ '733,1.. i' r
<br /> T,i » �I},n EXT r w tr..,. s• t 1 - k BOS DISTRICT I1, z '+'`s LOCATION CODE'•
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<br /> iPHONE2
<br /> H.L.
<br /> ' FCONTI2ACTOR 1 SER�CE REQUESTOR
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<br /> Q ' Samantha-.,Iaou�-i rr 5 ( I ' 4��`ts. .I ( t � , _5 °' -x CNEC1CIf.B1LLINGI�IDORE55 _
<br /> x -' BUSINESS NAME,. ArCV�S3.fOT1 `"InC f" r' r 14 ''" cx,Er I e r �+" I p314 4 ' — $2 T
<br /> ] 52400 ' .2
<br /> HOME or MAILING'AAk
<br /> DDRESS (31'[J e k415-2 3.fl 0
<br /> 1950 :-C Rd Ste.:_:300, " -. ,
<br /> t;ITY STATE':rMO` 'ZIP 63.1
<br /> St'. Louis
<br /> 46
<br /> BILLING-ACKNOWLEDGEMENT I;tthe undersigned"property or b'uSlnesa;..owrier,I operator'or authorized agent of same,
<br /> } acknowledge that'all.site and/or'project,specific ENS11ioNMENTAL.HEALTH Oe PAr�MENT;hourly charges associated.with this project or
<br /> activitywill be billed to or.Tny•tiusiness as'.Identifietf.'ori this form.'
<br /> I also certify that I have prepared this application andlthat:tha work to be performed"will be done in accordance with all SAN JOAQUIN
<br /> CouNTY Ordinance'Codes;Standards;STATE and FEDERAL lauvs..,
<br /> { APPLICANT'S'SIGNATUREr s 1 r� {G`. DATE•
<br /> .PROPERTY/BUSINESS,OWNER'�,' OPERATOR(MANAGER.Di OTHER AUTHORIZED AGENT.® permit coordinator
<br /> IfAPPLi&ANTIs not the 8iWNe F'AaiY:.PrOot oFi&fh&riza6oii.fd sign is,requlred Title
<br /> AUTHORIZATION TOAELEASE INFORMATION:When applicable, I,'the owns#r or operator of the property located,at the above
<br /> site address, hereby,a.uthorize the release of any:and all results,geotechnical data and/or environmentallsite assessment Information
<br /> to the SAN JOAQUIN.COUNTY'ENVIRONMENTAL HEALTH DepA�RTNiEkT'as soon as It is available and at the same time it is provided to me or
<br /> rmiy representative, i
<br /> I TYPE OFSERv1cEREQUESTED. add• bar intolobby lobby of existing movie theatre
<br /> COMMENTS:
<br /> f
<br /> 1 , .
<br /> ` ACCEPTED BY: f LJ`� PAA Ut� O EMPLOYEE#: DATE: Otn 3 �,o
<br /> ASSIGNED TO: `'"� 4 EMPLOYEE M. DATE: �V
<br /> 1�acl� n-'n �i n h , �� � �
<br /> Date Service Coinpieted'{if already completed}: . 5>RVICE CODE: G CJ��j Pl E_
<br /> Fee Amount:, d` 6 Amount Paid 6�: C� Payment Date 6
<br /> s Payment Type. G L Invoice"# Check# 3 �(� Received By:
<br /> [JAY iVl t- \4 1
<br /> RECEIVED
<br /> Q!D 48-02-025oi ����� fy 9 ��{� SR FORM(Golden Rod)
<br /> ,I U :} 1
<br /> 4; 5AENOA� IN CCUNTY
<br /> MF-NTAL
<br /> HFALTH DEPARTMENT
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