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BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws.E- <br />APPLICANT'S SIGNATURE: DATE: os/a/z(4 <br /> <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />71C,' (.1903 <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name k A <br />r 1 i t't 0 S A- S s0 C 4 A <br />Site Address <br />600z p4 6 /PC aye- <br />City <br />S' red cz.t./0 el <br />State c 4 ZIP <br />is--20') <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments chc).-r\cie oc ow r-wif s--fa;k e <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party 0 Facility Owner / <br />M4 re Ad a Cel ei.- 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name i <br />jah n cod; Last name If contractor, indicate type and license number <br />Address <br />02 Lf pl(C-( F/ C 4t/ Z._ <br />City <br />5 rv c..44-1-v •-) <br />State <br />C At3r <br />ZIP <br />cir C-1.? <br />Phone <br />zoey 2.00 81-06 <br />Phone Email <br />-10A riq ocitt9t5(....-)clancecre, coin. <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor <br />PAYMENT <br />0 Architect <br />First Name Last name If contractor, initzEtEfittine number <br />Address City State MAY 1 ZIP - <br />3 2024 <br />Phone Phone Email SAN JOAQU <br />ENVIRONMFNTAI <br />N COUNTY <br />HEALTH DEPARTMENT <br />Accepted By— ,r, ,- . Assigned Tq . , <br />Lyda n Linked FA ID <br />FA (DM 2-2-5-1- <br />Date <br />5 - 1.3- DA- PE RD02_ Fee 41t,z .00 Record Number <br />e62.4 a'ciA 05 <br />?el J=t/U 3 b g 49 I