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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 t j.Jlin ar1 that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL I <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / BUSINESS OWNER OPER R / MANAGER LI 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 />DATE: <br /> <br />0•Cf12 o-2-L <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name Di_ri .1 1-1-hy F-00c . 1,1,e. <br />Site Address <br />0 N . T30711cto SV • <br />City ctte_4\.) State eit ZIPct , 2°2 <br />APN Supervisor District <br />Type of Service <br />Requested <br />:A/Application for <br />Operating Permit <br />'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 VIN <br />Contact Types <br />required <br />Billing Party OptifyrfaskrA XFacility Contact 0 Property Owner 0 Contractor 0 Architect <br />yBilling Party 0 Facility Owner AFacility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Narnt-41. i i' <br />I % ‘k p <br />Last name <br />iN4 0/149){1 '8-f • <br />If contractor, indicate type and license number <br />Address ci 2.....3s 3 LA ctiAbev•-• C-k- • ixi , <br />t ilAvOp <br />State 0, ZI <br />ikl 3-- —3 0 <br />Phone c,irj <br />1-2. -5— Hi -2-1 <br />Phone sk 0 <br />-2_0 - I-1 g6 g <br />Email <br />cl,,,,„,--N.,.0010 40.0.;\.coNN <br />-• <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, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />Accepted By (ik A si ned To AA, <br />11(0'0 <br />Linked FA ID <br />Da te(AN <br />PEirevey Fee Record Number <br />, <br />PR 24 00249