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ply <br />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 is ai4licati n and that the work to be performed will be done in accordnce with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEEEM%aws. <br />APPLICANT'S SIGNATURE: <br />*PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER Li 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 />DATE( 11- 31— 2ot <br />D New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name _ o <br />\O -I Gc 0 <br />Site Address <br />240o t 05 Y- ii 6 c 19 ;"i tA., 41' ki , - \ - <br />Supervisor DistFr <br />n <br />ct <br />City i <br />S-\er.K toiu <br />State <br />(-6 \'c-DANtA , ZIP <br />ci _Ts- <br />APN <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 <br />COY\ SC4-1:A--- 14 <br />iiv2.„ % 4.,_____ <br />If mobile food truck or <br />pumper truck <br />cff <br /> <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 El Facility Owner El Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Fir A Name , \ <br />LIC4 v NC\ <br />Last...name 1 <br />(1.01 Z <br />If contractor, indicate type and license number <br />Address <br />3'1i 6054c10,a ikko‘y <br />City <br />5ACC VI i'O''ki <br />State <br />0 6 I lic-oi kici <br />ZIP <br />6iS ZO 6. <br />Ph <br /> r6c <br />e.A ) <br />6 g‘ZgaS <br />Phone Email <br />-0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner —1 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 El Property Owner 0 Contractor LI Arcekq <br />T <br />h,,, <br />' PIMEN) <br />and IiiECENED First Name Last name If contractor, indicate type <br />Address City State ZIP , • n - j 1 2024 <br />SAN <br />Phone Phone Email AQU/N jo ,., <br />i.4 ENVIRONIt4p''APON T) —EALTHD -;—TAL <br />Accepted By v Assigned To <br />, 1 0. Vliv-r-0 <br />Linked FA ID <br />ouziu 0 Date <br /> <br />PE <br /> <br />• Fee <br />n 2, Record Number <br />14 P,)(-1 Di <br />A(Cash# I 72 .0(D 0 Check # 0 Confirmation # <br />Payment <br />Received By <br />Rev 07/10/2024 <br /> wositSt10-