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BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ackke64424 riVior project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as i e•Farcid on this <br />form. <br />I also certify that I have prepared this application and that the work tre performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDE s. <br />APPLICANT'S SIGNATURE: <br />ErkOPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br /> <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 />DATE: 67 <br />0 New Facility X:k Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name i <br />b-tOVe O.'(" 4-0.e creNr- <br />Site Address <br />C CAI 0(til ( <br />City State <br />(.-A <br />ZIP <br />g . -eC-f) <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />111-CiiirstAation 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 />4-ni )k7 I 3 z <br />VIN <br />1 7_ ci -2-1-c f z7 FRI 1 5 3 <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Willing Party X Facility Owner A Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />‘s2 C6 •eti , C k <br />Last name <br />711-e (7 - <br />If contractor, indicate type and license number <br />Address <br />CI C 0 S C-1 Ck i IC 1' f 1cl -C(- A---fr5 City , co , State c ,-., ZIP 7 9 z ei 0 <br />Phone <br />Z rei 2--3 7 Vc;(7b <br />Phone <br />ES1144.f ids Til W'gi-aN <br />-IC( eye •Coirn <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 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 />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, PAY'i , ) <br />RECEIVED <br />State <br />AUG 1 9 <br />: ; T n s e number <br />ZIP <br />2024 <br />Address City <br />Phone Phone Email <br />SAN JOAQUIN rill INTY <br />Accepted By <br />:Secç C. <br />Assigned To Linked FA ID <br />Date <br />Q)B.1 k Ct t 2_02-,4 <br />PE <br />icocb-3 <br />Fee <br />$(12-(2)0 <br />Record Number • — , <br />Sq. 2Li QX.6,4q)-1- , , <br />*ash 0 Check # 0 Confirmation # <br />Payment <br />Received By <br />Rev 07/10/2024 <br />1712094 (010