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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 work 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: DATE: 05/13/2024 <br /> <br />E 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, hereb authorize <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 Pe2_0(X491-1 <br />Facility Name A.ICE <br />Site Address 2401 W TURNER RD STE 275 City <br />LODI <br />State <br />CA ZIP 95242 <br />APN 01530006 Supervisor District 4th district <br />Type of Service <br />Requested <br />IE 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 VIN <br />Contact Types <br />required <br />El Billing Party GT Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Cil Billing Party NI Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name DEZHI HUANG Last name If contractor, indicate type and license number <br />Address 9045 RIETI LN City <br />STOCKTON State CA ZIP 95212 <br />Phone 2096237928 Phone Email <br />teddh86@gmail.com <br />12 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 _t.-- <br />7 , 17 <br />Assigned To ,..— 4-, ..,,,... <br /> <br />Linked FA ID gle <br /> <br />Date <br />SI I tillA <br />PE <br />°C11-L\ <br />Fee Ai <br />A1-55 .(910 <br />Record Number p k24.4crosAtc,, <br />0". <br /> iouualf—giz-241-3