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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 CPA <br />RAL law. art 1 '11 ri I 2-6D4-- Rec <br />DEc 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required SAN jati <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby/010140 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL M 410 4./Ep <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br /> <br />Title <br />El New Facility Existing Facility. <br />San Joaquin County Environmental Health Department <br />Application Form nowskm3 a (deo C.ti& <br />/oc) a/ Tce,rnel- q 54 eF zo AN aralcv <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation Xchange 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 />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />11 Billing Party Facility Owner g Facility Contact 0 Property Owner 0 Contractor CI Architect <br />11.1, • A e. Lec. <br />If contractor, indicate type and license number <br />1111!,-Q,1Z <br />--1 rill <br />M3 5eDa_Ve Lk? ,cr i cz v j <br />1111b- 90 a Phone Har,144 R170 .9-7,62,1 6-erWi <br />0 Billing Party 0 Facility Owner CI 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 />CI 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 <br />J-e C. <br />Assigned To <br />Francisco R., <br />Linked FA ID <br />FA0000117- <br />Date tzloqizozq PE 1602_ Fee <br />-1 a i <br /> Record Number <br />az zgaracqz. <br />0 Cash 0 Check # "Confirmation # .9 as2 Li LI of3 "ii <br />Payment <br />Received By <br />Rev 07/10/2024