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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 I s. <br />APPLICANT'S SIGNATURE: <br /> <br />vo/zs/q <br /> <br />DATE: <br /> <br />0 PROPERTY / BUSINESS OWNER 0 OP TOR / MANAGER ID 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 />ri New Facility )2;(' Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name giefrii8/4 ,.—,35--e,i6-7S ti <br />Site Address /i e tp.i#vvviLf.-.€._ c A.,, <br />City <br />srcr-tc-roi-) S te ZIP 95 1/0 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation . ,Change of Owner 0 Repairs or Remodel 0 Other <br />Comments N (RAJ 6 tAl INA,' ‘‘A__co_ez.* a.-• <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 />NBilling Party 156-acility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Narr.IL_. <br />//P1'' ---,44:2241CPS2 <br />Last name <br />N Eilt.,11J <br />If contractor, indicate type and license number <br />Address 73 24 Lee-le-47Q 9 f(_ r -71C_YZ-A4461"41:-) <br />State <br />CA- <br />ZIP <br />9S—X 7--‘37 <br />Phonelt (.. 0 4 ,c1.4. one Eniail <br />17#1,4 771/4/ .. ZS. e &WA/ L . CAYV1 <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 />1 <br />If contractor, indicate typeAni <br />ri, A.. .r:otwertt. IV 1 <br />WEIVED <br />d. Ijc9ns,2 number <br />5 N Z 2024 <br />First Name Last name <br />Address City State <br />SAN <br />ENVIRONMENTAL <br />ZIP <br />JOAQUIN COUNTY <br />Phone Phone Email <br />• HEALTH DEPARTMENT <br />Accepted By UeR C. Assigned To tQc...v_ uo. Linked FA ID <br />*FAO 021 F3e3 <br />Da PE Fee SAL,-2.. Record Number <br />5R -2.1-1002(0.4 <br />//IV/ KV-08r 4/