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IF <br />(A <br />C <br />i <br />L <br />1 <br />T <br />Y <br />O <br />N <br />T <br />R <br />A <br />C <br />T <br />O <br />R <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUN COUNTY <br />j, East Weber♦ Floor, Stockton, California 95202 <br />Telephone: 0' (; ('' <br />) 468-3433 <br />Q - • _! 1 1 <br />Mmam`1 t� <br />� ` "A .ilill <br />.�tflr'i 7 <br />i_ � �- • •. sa •.: �_ •....•: ��t �.r= r ,y ♦c• i—rte -• • ♦_• <br />Indicate the responsible party to be billed for addilliOnal EHD staff firle expended beyond permit payment ociverap per tanL V <br />the party designated below is dillierent than the permit appkail eg. property owner, ff�e party must acilicrowledge <br />resiportsibility for the bArni by signaftue and date below <br />NAMI�l' 1 �_ ' �1 1PHONE#i <br />F <br />w , <br />SIGNATLR <br />EH23D= (revised 8M=) <br />