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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 application and that the worl ,to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />,(APPLICANT'S SIGNATURE: re-e- re/kt DATE: •(1 <br />PROPERTY / 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 />FAo606713 <br />-7 K2-41-co.2.31 pAv _e <br />San Joaquin County Environmental Health Department RecgveN T <br />- Application Form 'V t- MAY _ , u am <br /> <br />Facility Name „ <br />SAN.in —,AQI JI A, <br /> <br />/,'u h ()def.,- 1:i fe... <br />ENVIROA/ " COUNT <br /> <br />Site Address L <br /> <br />Z a l ,z,ne A) City, <br />-77kdif ter - <br />State <br />c,:= .-.-- <br />11.Kr4 ...,Ampu. (A <br />APN Supervisor 'strict <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 consu A-a-Hon <br />If mobile food truck or <br />pumper truck <br />License Plate Number 41)54549 VIN vi T. i l 4 -19 <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />ytBilling Party ji1 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />FirA Name i <br />/"2".-1—(1 r Last Mme <br />g V?. 12 <br />If contractor, indicate type and license number <br />Add ress,_ <br />613 ( 3 I.) el r79 e 0 C el e") (2 r <br />City, / <br />/ fr4edd a ik) <br />State ZIP <br />1,7ne __,3gs,..--0 t53Phone <br />___,c//'? <br />Email <br />kr7a 7246agi en-7,7 <br />1/1 <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 36 c. Assigned To _ <br />: 6 I ci 1 1 <br />Linked FA ID <br />Datez-AwDzil <br />PE Fee I ito z (i. At, 649— Record Number <br />'r • <br />ce41.7 /2012_ 1312L, a t(,Q/417- -0/3(74 <br />abx-r. )zt67? )74-