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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 specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be perfopmed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 0 PROPERTY / BUSINESS OWNER RATOR / MANAGER OTHER AUTHORIZED AGENT Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is requi AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. DATE: o(dby,(24 San Joaquin County Environmental Health Department Application Form Facility Name Site Address 22'2 6 . •-1 rnt 1-e_. f\-, City 1 State ZIP APN Supervisor District Type of Service Requested 0 Application for Operating Permit 0 Consultation 0 Change of Owner 64.epairs or Remodel 0 Other Comments pelit44 094 J_Lut iv -e--Nre If mobile food truck or pumper truck License Plate Number VIN 'Contact Types required 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect Billing Party EVcility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First NrAey.) Last flaw If contractor, indicate type and license number Address c,,Dr-rc.- (-Ar-c-- City 1 State ZIP Phone (20q ) (102q- el 2-1 1 Phone Email A - net:›Qe-ack 21e...714 -Alma CO 01 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect and licene447 li,c,...„.EN First Name Last name If contractor, indicate type Address City State ZIP cliepi. . i JUN Phone Phone Email 0 6 2 81" JOA 0;4 4 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor ISARIAlkii""/7"):01 r -76-iv r First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email Accepted By ^._ Linked FAD.... Assigned To -tr-clkfrt&,-( Date PE Fee j Record Number sa2L Ica 2 24/ 6)t g