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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 />-64/eruy, <br />$4.ERIATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <br />DATE: <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 />Standards, STATE and FEDERAL law <br />APPLICANT'S SIGNATURE: <br />El PROPERTY / BUSINESS OWNER <br />Zk a0 <br />El New Facility <br />0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name ..„-- <br />1 n cAtia, 1 <br />r te-r Sc./toot <br />Site Address <br /> <br />J\r C PI O il ' Onr4 -Up 110t0 4 City <br />tcal <br />State c ZIP <br />9 53 -2 V <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />ig.Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments , <br />''- 1 k Vert 1-4t.C.:4rit r(VV6S ' ,CfeALA.Ai W‘tS She/evil-5 . acklx,e,,i 61-+ \pica+ <br />If mobile food c1 or <br />1 <br />pumper truck <br />LI nse Plate Number <br />. <br />VIN <br /> <br />COrP4,'Ai 0 Property Owner LI Contractor LI Architect <br /> <br />pilling Party 0 Facility Owner El FaEllity Contact . 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />1-k) SD Food ,CQ.-M. Ce/S <br />Last name If contractor, Indicate type and license number <br />Address <br />1 1 5 VI ' L4h4lell 4Ct- <br />City <br />1 Irilel <br />State _ ZIP <br />Phone <br />49 01 33D .5 55 <br />Phone Email <br />‘y,ampetifp livsa. <br />0 Billing Party 0 Facility Owner X Facility Contact 0 Property Owner 0 Contractor 0 Architect- <br />_ <br />Fir;t-h.....7c Last If contractor, indicate type and license number <br />...-, <br />Address/ <br />(,Di f/J`t if idtvt <br />Cit'' <br /> <br />-- y„-- <br />I <br />State cn ZIP qi53 -1 0 <br />Phone <br />(244 330 3,Q <br />Phone Email <br />El Billing Party 0 Facility Owner <br />t <br />0 Facility Contact 0 Property Owner o 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 />c.CPi3.tg.d ,ti. ,.. - <br />Assigned lo Linked FA ID <br />E Fee Record Number <br />Rev 06/12/2024 Q:3 Li Lk Li 9' c:\ <br /> <br />t 052.1 'acts