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0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Arcpett„ , <br />AYMENT <br />First Name Last name If contractor, indicate type and lifiEGEWEE <br />Address City State ZIP JUN 1 0 202/ <br />Phone Phone Email SAN JOAQUIN COUN <br />ENVIRONMENTAL 1 ir-ei I MI nc ,, <br />I <br />,n,.," T <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 this application <br />Standards, STATE and FEDERAL laws. 'Pr <br />APPLICANT'S SIGNATURE: I.. /ye <br />at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />DATE: <br /> ne- /0, 2.02z/ <br />.bg PROPERTY / BUSINESS OWNER <br /> 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <br />It 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 />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Pan P;nCa9 649 &.4S---CALI P14 <br />Site Address <br />1 (DI CI ff WV OZ LOM 4/20 <br />City <br />zt.c4aDn <br />State <br />ca <br />ZIP <br />952,1b <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation riCh.live of Owner 0 Repairs or Remodel D 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 'Property Owner 0 Contractor 0 Architect <br />,Billing Party 0 Facility Owner 0 Facility Contact (Fi Property Owner 0 Contractor 0 Architect <br />First Name <br />ceLesie <br />Last name <br />A.Ar-010 <br />If contractor, indicate type and license number <br />Address <br />toctio car-rgio r og Ve <br />City <br />cirocia0n <br />State <br />ca <br />ZIP <br />qsacq <br />Phone <br />aCCI VP 61 2c1 <br />Phone Email <br />ceiclu G.. g a (OD ,Lareo• cDrn <br />0 Billing Party Li Facility Owner 0 Facility Contact 0 Property Owner CI Contractor 0 Architect <br />First Name <br />ilActArt <br />Last name <br />Wcee-AD <br />If contractor, indicate type and license number <br />Address <br />q a i 8 fcia,e. to oar <br />City vocAvn <br />State <br />Ca <br />ZIP <br />cf9)-0 <br />Phone P Einail n ail <br />Accepted By Assigned To . , Linked FA ID <br />le C N kc...-- w • -':- R Cla 2(G2:bb, <br />Date , PE <br />VDOZ <br />Fee <br />$V0 2. 00 <br />Record Number <br />SR-2.4i102.2b <br />IS2461V1-1 /11/2/1/ AW 2-0 4- /2_____ <br />AVOSSWIctt