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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 ap at. n d th the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FED AL law <br />APPLICANT'S SIG NATU <br />PROPERTY! BUSINESS OWNER 0 OP TOR / 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 02 3 -,2 41 <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name b Ja. <br />lb <br />s <br />Site Address <br />02 49,3 10. 0202 nd <br />City <br />FraeV <br />State et9 ZIP <br />15371.0 Sfree <br />APN <br />baized 6004 <br />Supervisor District <br />Type of Service <br />Requested <br />,Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />? <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />Ira Billing Party jo Facility Owner "(Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />g Billing Party $ Facility Owner A Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />NeaMer <br />Last name <br />D rt4 ni 0 00 8- <br />If contractor, indicate type and license number <br />Address <br />2f3 k2 . ig.r 4 Sfree74- <br />City <br />Tr aCY <br />State <br />a/4 <br />ZIP <br />95(3 74,0 <br />Phone <br />2co--&0-11,91/ <br />Phone Email he.4the..,- ar afrtz- 11 e .03mai I . cowl <br />El Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner El 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 />PAvilificiii-i, <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor Ilt Cffiliftel) <br />First Name Last name If contractor, <br />SAN <br />HinelicidATI.:0"p <br />e6EP4ARIT <br />iit:InNTumber <br />140 COUNTY ENVIRONMENTAL <br />Address City State JOAli <br />Phone Phone Email <br />Accepted By Assigned To ti Linked FA ID <br />FA- ke..A/11,Kit___ <br />Date 24 PE (roo at Fee /I i 8--z, Record Number <br />2b VL& /s. qo rt.; 4a1,-/ter <br />votAontAi