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0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name <br />A/C1-10' <br />If contractor, indicate type and license number <br />Address <br />f' L' 6 -, 4 0-2-e 04 As i7/ <br />City <br />5 (c7 c ik fait, <br />State <br />6-7/l4 <br />ZIP <br />q k-'7 • F7 <br />Phone <br />12995-/41. 375-- <br />Phone Email <br />0 Billing Party O Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor CI 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 contractorfAYM <br />RECEInp <br />State <br />DEC 12 <br />NdTcense number <br />2024 <br />Address City <br />Phone Phone Email <br />SAN JOAQUIN couNry <br />ENVIRONMENTAL <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, hifiAlakidlEnteirMaitrd/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 plication and that the 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: <br />GI PROPERTY / BUSINESS OWNER OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT <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: / — 42-c/ <br />New Facility c:Sr Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form -Fkos4-12-toi <br />Facility Name <br />1— 4 /-' Af 0 <br />Site Address <br />/3o2_ (7 '.17_, <br />City State ZIP <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />AConsultation X Change of Owner 0 Repairs or Remodel 0 Other <br />Cornments <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />4.-ri All< ( ) ci 2_ <br />VIN <br />i-itixfr<c -2/-2-2.-4--17/7/1/ <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Accepted By <br />C g c. <br />Assigned To <br />C-1 ; cj i F <br />Linked FA ID <br />f-1\ MD-45 Goco <br />Date PE Fee Record Number <br />12112. 2-02(-1 -3 l4,0 .n 2 S R 24 Viii-tyi <br />1-6-sT, o Check # 0 Confirmation # <br />Payment Z / <br />Received By L--- <br />Rev 07/10/2024