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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 applicati • ; . • hat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERA <br />OPP APPLICANT'S SIGNATURE: <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER <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 />gil ad/A-I/it <br />)(OTHER AUTHORIZED AGENT picx 016y\ (WatriaTLY <br />Title <br />DATE: <br />nrite(a Tall6 n <br />f- COM MO WVI(e.1 <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facil ty Tsnev3 <br /> <br />, . <br /> a N VSOW tk\i{ <br />Site Address <br />11 ‘940C — 0 th0kt AV t <br />City <br />tkk(ki \\ Q Ca <br />State <br />C(k. <br />VP <br />qL3-5-1 <br />APN Supervisor District <br />Type of Service <br />Requested <br />Application for <br />ôerating 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 Facility Contact K, 0 Property Owner Cl Contractor 0 Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor Cl Architect <br />First !lame . . <br />1 LOC), .., -- -- Address , . <br />Last name , <br />f'N ANIttr <br />If contractor, indicate type and license number <br />n.... <br />yil-k(u• <br />State <br />c.6.. <br />ZIP <br />q 5 331 <br />Phone <br />7iJcAik-voi V5 I <br />1.$) ilvikci it\ to Nt • <br />Phone Email ,t,\,\viciritk.k co Kele (A - ow <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 ( re /i a C._ . , F. Assigned To 67 , LiniMg.m <br />, 1/13 gS <br />Date PE Fee RelorrQunitl;e7 <br />Cb310C 1-103 <br />+VI 6,6 javis_ 21). / 202 # pR21A0DvA3