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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 specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared his application a/nd ha he work to be performed will be done in accordance with II SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERA aws APPLICANT'S SIGNATURE: a \ikM Cl-0 PROPERTY! BUSINESS OWN CI OPERATOR! MA 'GER 0 OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOACV N OUNTY VIRONMENTAL HELFt DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. 14- (n-OV DATE: Title 1:1 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email •\/ 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor IrtrKitect First Name Last name If contractor, indicat t pe nd license er Address City State ZIP CiC° Phone Phone Email 0 r Billing Party 0 Facility Owner 111 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name cmot _car Lakt /t ame 1 rart02., If contractor, indicate type and license number Address \--I u) CCU( \ t S'\-- City I C\\)(' State ZIP qC 166° Phone Phone Email San Joaquin County Environmental Health Department Application Form Mg OOtP Facility Name ick,\\c Ice Grew Irlic- Site Address - :./. State ZIP _ k a(0- Vi NU f \Ni\e 34 1 CILStY t)C W it\ CO q\ 2-0G APN Supervisor District Type of Service Application for Yperating El Consultation 111 Change of Owner 0 Repairs or Remodel 0 Other Requested Permit Comments If mobile food truck or pumper truck License Plate Number ---Inc)1P3 VIN \16ss311,2tokk-Tt "))'/11 Contact Types required 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect Accepted Accept \ Cita Assigned To CAO.L.L.Click M Linked FA ID rAvi, 0( Date C05 l'at 12_02_4 PE k(o'2J-k A_ 104QC.D Fea,, 1.) Record Number ,R24 DOIE, 5 Pd- #1(57.00 151717671 461s1-