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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or PropertyFACILITY <br />ID # <br />SERVICE # <br />H O T E L <br />FAX # <br />.EpUEST <br />S►Q lo`Ic�3- Z -I\ <br />OWNER OPERATOR n <br />lJ E67 "CIS T E I -N <br />Q 1, {��(( <br />I' .5 I 1,-1 N 6 S U 1T 1. V CHECK If BILLING ADDRESS <br />FACILITY NAME HARd HOTELS LLC <br />ASSIGNED TO: <br />SITEADDRESS <br />6411 W bANNEf- <br />I <br />DATE: <br />Date Service Completed (if already Completed): <br />LDDI CA <br />45dti�, <br />Street Nomber <br />PIE: <br />' 0 <br />u. <br />Street Name <br />Cil <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Invoice# <br />Check# 13b-6,37605 <br />6 A U BUP N. L \/ D 6 U I T E <br />131 Dal'..' <br />Cs r <br />Number <br />Street Name <br />CITYSTATE <br />ZIP <br />c4A CRA N-16NTD CA , q5 sal <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION p <br />e' ,^ <br />(M ) $13- 7VD <br />6 <br />PHONE'#2 ExT" <br />(Mil)361-3000 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />N A CHECK It BILLING ADDRESS <br />BUSINESS NAME N 1 A <br />PHONE# E%T. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <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 />1 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 />COUN"1'N" Ordinance C'rldes, S'fmularde, S' A E and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 0� `M Rost I <br />PROPER f) / BUSINESS OwNERE(i)PERATOR/ MANAGER OTIIER AUTHORIZED AGENT 11 M A N ACS I rK) t`1 tH &E L <br />l(.-Il'Tf.A'dwT is not the BILLING PART) proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 enro ental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL- HEALTH Di-TARTMF:NT as Soon as It is available iii6same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />D�C <br />B <br />T <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />2I <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />NO <br />PIE: <br />' 0 <br />u. <br />Fee Amount: <br />Amount Paid /Sa, D� <br />Payment Date <br />Payment Type '"G� <br />Invoice# <br />Check# 13b-6,37605 <br />I Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 �2�5 Zlv3v5 SR FORM (Golden Rod) <br />