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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)aws. <br />APPLICANT'S SIGNATURE: A • <br />0 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 />DATE: <br />r-A.00010s-I <br />P 21-oo San JoaquinJoaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />MO oftt cill k lc E ( ei---'lm ' <br />Site Address ;City <br />ii?‘.- Mr/2 ,7 r?,41-7 rt) ./.) i ) 7 <br />State ZIP <br />(4( S 3.5/ <br />APN Supervisor District <br />Type of Service <br />Requested <br />Q Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />CiltfAifi Ai kroi <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party <br />'tit-4644AI <br />'0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name a HA 0 II Last name kit iv) If contractor, indicate type and license number <br />Address <br />/s - LI v Err gniv 5- 7 <br />City <br />mil Ai i t e 0 <br />State ZIP <br />Phone <br />411_ 114 5. //4 <br />Phone Phone <br />dieg'-i)}!--1-0-!4 <br />Email <br />905 INy octimya(„74) 301 15; IL... ri- :11) <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 />PAYMENT <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor <br />If contractor, indicate typelUtte0s3nu2024 <br />illpk,jtve ID <br />First Name Last name <br />Address city State <br />SMU <br />HEALTH <br />AQUIN COUNTY <br />RONMENTAL <br />DEPARTMENT <br />Phone Phone Email <br />Accepted By , . ,-. <br />J <br />— i <br />Ck V __, <br />Assigned To Linked FA ID <br />• Date _ ., jciii(1,6 2.,4 PE. A -,,,,, Fee $ Record Number <br />3R2440021 . . / 2_ <br />' eioN>r v41,4 64/L-0-71 --0/247 CAA, 4 10-- I, ,24 A/07- s