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HEA, RONMFNTA tVI <br /> dMrPOr BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site a WARART/i4n NT 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 laws. <br />APPLICANT'S SIGNATURE: DATE: 5 --06— <br />reYPERTY1 BUSINESS OWNER 0 OPERATOR / MANAGER 0 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 />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Namee <br />Co Ci1C-krAA S <br />Site Address State <br />ciyak <br />ZIP <br />61.E17----4 <br />APN Supervisor District <br />Type of Service <br />Requested <br />FL Application for <br />Operating Permit <br />0 Consultation D 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 li1 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party VI Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name a <br />deka. irCi'Mt0 k-UX INCAM LastetztA A _ <br />cy-a, )NA <br />If contractor, indicate type and license number <br />Address <br />2_463 (A.) y tt. v\ 'a lA <br />itt y,,AtA:sorr State oitic ZIP <br />CCS-3 3 0 <br />210Phon)(..i)APhone Email <br />$1)(Ces dtarmcs4-yacye vAlAk.ccaN, <br />?a Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name r i <br />) COL9C6.A\S <br />Last name If contractor, indicate type and license number <br />Addre <br />4—ss (n) (.6til ck-re--12-k <br />,LIAL—t <br />'Val <br />State <br />C--A <br />ZIP <br />Phone Phone Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />and license PAYME <br />RECEN <br />ZIP <br />jUN 0 6 <br />First Name Last name If contractor, indicate type <br />Address City State <br />Phone Phone Email 2 <br />SAN In ....k.AQuipu ne, <br />Accepted By WOO Assigned To 1(4. oie Nile linked FA ID <br />00‘)-92309 <br />bati <br />PE t11109. <br />Feet 1(0),010 Record Number Spy 009,2-5 <br />NT <br />ED <br />24