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El Billing Party OFacility Owner OFacility Contact OProperty Owner 0Contractor 0Architect <br />First Name Last name If contractor, indicate type MOMENT <br />RECEIVED Address City State <br />Phone Phone Email 1 3 20211 <br />est LAITY <br />0 Billing Party 0 Facility Owner OFacility Contact OProperty Owner 0Contractor <br />417imigahlm NTA1 <br />HEALTH PR'. ARTMENT <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL L pi <br />APPLICANT'S SIGNATURE: .417 n q. <br />PROPERTY / BUSINESS OWNER OOPERATOR / MANAGER 00THER AUTHORIZED AGENT <br /> <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: <br />San Joaquin County Environmental Health Department <br />A lication Form _ <br />Facility Name ..e.ilv/ti y i C e C <br />Site Address 54i 24, maii6g Ave <br /> <br /> c tO C.000 <br />City State <br />C 4 <br />ZIP ot •-'2,0 5 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0Application for <br />Operating Permit <br />0Consultation OChange of Owner ORepairs or Remodel 00ther <br />Comments , <br />MV (_ 1 ce (Ix eo,m ) <br />If mobile food truck or <br />pumper truck <br />License Plate Numbers Ai 4 7/ 70 VIN <br />jek-96? /*5 T59 (13677 0 <br /> <br />Contact Types <br />required <br /> <br />0 Billing Party <br /> <br />0 Facility Owner 0 Facility Contact <br /> <br />0 Property Owner <br /> <br />0 Contractor 0 Architect <br /> <br />W Billing Party VI1,Facility Owner OFacility Contact OProperty Owner 0Contractor 0Architect <br />First Name <br />/t4d#A fri/M1). <br />Last name $ hi, 0 ,e (f? If contractor, indicate type and license number <br />Address 82 ,y? — , e-havnbord PI- City <br />5 tbc 01)41 State <br />c /;/ <br />ZIP <br />96 2fo <br />Phon <br />5)g/ 2 V 1/ 54 Phone Email <br />Accepted By Jo c Assigned To <br />C \ CW1/4 6:I C.L. III‘A • Linked FA ID <br />Date <br />51/M14 <br />PE <br />CrAD3 <br />Fee <br />$ Cv 2 (LKI) <br />Record Number <br />(:P•e2-i4CDCD i 10 I <br />112 - Ct45 6- 3 /2 7; 7A/ <br /> <br />Q1205-319- I