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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 pp • nd that the work to be performed will be done in accordance with al SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / BUSINESS OWNER <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 />TOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />*9-4 <br />k New Facility El Existing Facility <br />San Joaquin County Environmental Health Department <br />App hcaton Form <br />Facility Name <br />N't R,es.Wog.ireJ. CiriecAims <br />Site Address <br />10twal CAMPAectOYt tal\f, <br />Supervisor District <br />City <br />qk o <br />State <br />OA <br />ZIP <br />01 5201 <br />APN <br />Type of Service pplication <br />Requested <br />for <br />trating Permit <br />0 Consultation ' 0 Change 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 />>/ Billing Party X1Facility Owner ,Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name esi \fict Last name • <br />NIKAA nYltillet <br />If contractor, indicate type and license number <br />Address <br />M114 QOP404040(e tkvNe. <br />City _,14-tim <br />State <br />CA <br />ZIP <br />C12.09 <br />Phone <br />14( li‘S..qa21 <br />Phone Email <br />ve44es. kr asted . covI-Fecti .s e,,..,1. Co. <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 />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 />Accepted By <br />JecC- c. <br />Assigned To Linked FA ID <br />Date <br />1-11(ot 2-02-'4 <br />I PE <br />1(00 6 <br />Fee <br />' 03(0 • aZ <br />RAcoprd2z l1 Number <br />00•90z