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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1IOTEL MOTCL <br />FAC�LI� D # <br />[� <br />BUSINESS NAME BEY W&57rU14 A <br />Ytt�� �XECVSIv'f� I N N '11 <br />SERVICE REQUEST # <br />QU <br />PHONE# Er T. <br />z L- oo 3 0 a2— <br />HOME or MAILING ADDRESS ILIs E, kioscmiTc RVc- <br />/�,y"� <br />I"NT� <br />FAx# <br />CITY M ANTECa\ <br />OWNER OPERATOR �i7 INV <br />HOM5 EST�1 N <br />1� 1 1 l I I yV C <br />CHECK If BILLING A00RE83� <br />FAauTy NAME. BLS -y VVC-S,TCRN EXK-VTIV( INN ANr) <br />Z 1 S ^'ZZ <br />ASSIGNED TO: �Z�I�ti1L <br />SITE ADDRESS M I SI <br />G <br />70SFMI T� f1V � <br />P T(--( /� 1 <br />AN <br />PANT( --(A <br />(7 �U <br />0" 53 16 <br />SVeel Number <br />DI ec <br />o1 a e <br />City <br />Amount Pai /E6, <br />21 Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Type V I� j,�— <br />Invoice # <br />Number <br />Received 8y: <br />tre 1 ma <br />CMStreot <br />D <br />STATE ZIP <br />RECEI <br />PHONE#1 EXT. <br />( ' <br />APNM <br />LANG USE APPLICATION# <br />DEC 15 <br />PHONE#2 En. <br />BOS DISTWCT <br />I�Dpry11GN CODE <br />CONTRArTOR /4ZlFRVTf'F 141MII117CTnll <br />NT <br />'ED <br />�zz <br />`r Ty <br />NT <br />REOUESTOR <br />GARy S\Nc,K CEO• 1iP HTC -LS <br />1NV65TMCNT INC CHECK IIBILLINGADORE55 <br />BUSINESS NAME BEY W&57rU14 A <br />Ytt�� �XECVSIv'f� I N N '11 <br />!'U 1 -I -f) <br />J <br />PHONE# Er T. <br />z L- oo 3 0 a2— <br />HOME or MAILING ADDRESS ILIs E, kioscmiTc RVc- <br />/�,y"� <br />I"NT� <br />FAx# <br />CITY M ANTECa\ <br />STATE C -A zip q '3' 336 <br />BILLING ACKNONVLEDGEAIENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTii 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 applica n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codec, Standards, STATE a id FEDERAL laws. <br />APPLICANT'S SIGNATURE: v`� DATE: _ 12-11512--2- <br />PROPERTY/BUST..NNESSOMINERLJ OPERATOR/ LIYAGER❑ OTHER AUTHORIZED AGENT 13 <br />IfAPPL/CdAT is nor the BlLLfyc 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 environmental/site assessment <br />Information to the SAN JOAQUIN COUNTY ENVIRONhPTAL IJEALTH DEPARTMENT as soon as. it is available and at the same time it is <br />provided to me or my representative.-G0-rF,r I Il / �y <br />TYPE OF SERVICE REQUESTED:I1Ll Vi <br />P () Ltil V-4-,✓ F (,'�-S U �7-t <br />J <br />COMMENTS: POOL I !SPA r11 V') <br />[) �,Cp t� <br />Tires -,,"I CI b <br />1((.� 1 <br />�V� tlQ l�` <br />/�,y"� <br />I"NT� <br />ACCEPTED BY: C t „ f.�' C' C' <br />EMPLOYEE #: <br />DATE; <br />Z 1 S ^'ZZ <br />ASSIGNED TO: �Z�I�ti1L <br />EMPLOYEE#: <br />DATE: <br />(7 �U <br />Date Service Completed (if already completed): <br />SERVICE CODE: Q /,. <br />PIE: • / - m' <br />Fee Amount: IS — <br />Amount Pai /E6, <br />Payment Date <br />t <br />Payment Type V I� j,�— <br />Invoice # <br />Check-7 <br />Received 8y: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />