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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 th ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required jai r, <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address her alize <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIR&WEATAL HEIT1.0/24 <br />, enji.in ae <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. QU/iv <br />"uN <br />Standards, STATE and FEDEL laws. <br />APPLICANT'S SIGNATURE: (' /."--- DATE: 1 - 2- - 2- 2-,--t <br />0 PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT ii, 470V Cote, Title <br />0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form Fi2 0 51 42_ (0(0 <br />Facility Name _ <br />Site Address t <br />6 -Lit liNi '2-54' L-1 S4-e--- o i <br />City <br />5A-006.4-o 1 <br />State <br />c- <br />ZIP <br />c z- 1 c , <br />APN Supervisor District <br />Type of Service <br />Requested <br />tat;--pplication for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <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 P-fIcility Owner 0 Facility Contact II Property Owner 0 Contractor 0 Architect <br />First Name <br />tal-(\l't <br />Last name <br />t'tst 104—bc\.1 \ <br />If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone EmajA <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 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />Accepted B A el/krz,-.10 • (4. <br />) s <br />Linked FA ID - latp.44::. mit • <br />14/670 RI cog* 5-1-P1 <br />Date <br />1( <br />PE Fee <br />$1-1-a • <br />Record Number <br />k 512 2 400)2 81 <br />paid etuce- -12-(21f