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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 appl d t t th,swork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />R0 ) Standards, STATE and FEDERAL I. <br />APPLICANT'S SIGNATURE: <br />. <br />DATE: <br />11,410PERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT ba\S <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 Name <br />5-CV--e- —1177-X1 k. \.. L <br />Site Address <br />11) 2- <br />City <br />O fiLt-i-c-e-c_.‘\ <br />State <br />0-.6. <br />ZIP <br />95331c, <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />'LW 1ri511 <br />VIN <br />'3 (-1°( CA ‘ C.5 Scttls-k 031401 <br />Contact Types <br />required <br />El Billing Party El Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />N14.1.3illing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />---7:COvkiJ <br />Last name <br />./31.-N.-+- <br />If contractor, indicate type and license number <br />Address <br />\ 6TC).. P.VV-f+)% e,C45.1-1•01-) Cir <br />City State ZIP <br />Phone <br />21-Lf 1-76 °SIDI <br />Phone Email <br />4-bt-ii-e_e-c.%-k.c,z.‘4., <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect pi _ <br />rwl kit <br />First Name <br />.--- 10..-pc-er-& <br />Last name <br />'—cre.-H.mg-g-ill-' <br />If contractor, indicate type and license Aro% <br />t.Zi <br />Address City State ZIP <br />/114Ya 1 . <br />Phone Phone Email 4 <br />1*.407.12PONLIS0/ <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect •,/w <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />Accepted By k., 5 Assigned To 1 ,-2 <br />I <br />Linked FA ID,... P- 002_11 5 3 <br />bate i I PE R.003 Fee <br />1 1 tr2 <br />1 I il-324.0- <br />Ren.: dp <br />ig 22-1] 67-e