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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 laws <br />APPLICANT'S SIGNATURE: • <br /> <br />DATE: X 0 1 o ( "vc <br /> <br />0 PROPERTY / BUSINESS OWNER <br /> <br />0 OPERATOR / MANAGER <br /> <br />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 />Accepted By <br />GOT It &SO <br />Assigned To iiik4vb <br />Linked •V .‘W- °DOI k k <br />PE tick) <br />0 Cash I 0 Check # <br />Record Number <br />0 Confirmation # 73? ?IS" <br />Fee Date # <br />'15 <br />4 <br />1 <br />Payment <br />Received By <br />1E1 New Facility 10 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Ne VJ St Li m Res-I-mitt an -i- <br />Site Address <br />2. 6 31) e. ri',i.morvt 5-1-re-e. t <br />City <br />S-1-0 c-a-Dii <br />State <br />kot <br />ZIP <br />.95 2 o 5. <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation %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 />ril Billing Party lif Facility Owner tiel Facility Contact 0 Proper y Owner 0 Contractor 0 Architect <br />First Name <br />2erirvq <br />Last name <br />Li art3 <br />If contractor, indicate type and license number <br />Address <br />51 14- 6 ra ri b be,a,n Ci r <br />City <br />C4-ock-i-DA . <br />State <br />CA <br />ZIP <br />q5 2t D <br />Phone <br />2oet-ccii,L - cli,(7 <br />Phone Email <br />shansko.n 6 3 3 il-gD hp+ meti 1. cowl <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 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />Rev 07/10/2024 <br />weAs1