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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 performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAk laws. — APPLICANT'S SIGNATURE: OCC(tC 0 PROPERTY / BUSINESS OWNER LI OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addressAW • thorize tO release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRO iteoitit DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. a DATE: 12 I (2- 4-1 PA Yik DEC 0 New Facility 0 Existing Facility San Joaquin County Environmental Health Department Application Form Pk) o Facility Name cc VO fA I col 5 (;) ac -Or\ 5r-k Site Address . _I_ c City lu cvv.\--L-- cc-, State CA ZIP _ g APN Supervisor District Type of Service Requested 0 Application for Operating Permit 0 Consultation VC'hange of Owner 0 Repairs or Remodel 0 Other Comments 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 COilling Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name k 1 U CCliCY,A • Last namer•N V3rvirn Er& If contractor, indicate type and license number Address (2- \ S_S CC^ q R. Cit (y),G,4_ State r a_ u-k ZIP Phone ,. ze -.2(4:41. Phon Email , rt o Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email Accepted By l y\A Assigned To 1 p - wick/ Linked FA ID 1-37A 00 2.,..k ..g, s ' Date rz 10 1,2(1 PE •/) Fee ..----I Record mber 141 0 DO CII licash 4:h --/d----- 0 Check # 0 Confirmation # Payment 4(.),.. Received By Rev 07/10/2024