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BIWNG 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 />d at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />DATE: (-7- 17 4.- <br />J ' <br />X)THER AUTHORIZED AGENT W-e CX-d;Crti 11 Co Ofa • <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 />I also certify that I have prApared this <br />Standards, STATE and FEIURAL I <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY/ BUSINESS OWNER <br />4 <br />, <br />ATOR / MANAGER <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility tame. <br />\9-k-Ol 6:A,\W 4- CbNC r‘ i Y \ V( \ Vn 1 -)'( \) k (*)?-i-) -- % ViVk oe NI e <br />Site Address <br />1 00131 Q( ,- )\) 1..itale PcNit <br />City, <br />nrtan-t-ecci <br />State Cc‘ ZIP <br />q ,--;----7 <br />APN Supervisor District <br />Type of Service <br />Requested ..s '-f.53 Application for <br />Operating 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 />El Billing Party 0 Facility Owner --Facility Contact <br />.. <br />0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party 0 Facility Owner p Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />1 CA‘rVo. 0(1. v S oh CA' k"-- <br />Last name If contractor, indicate type and license number <br />Address <br />2ric urvz.vv\A Le.,,,--,€ <br />City <br />i-elaywet 0, <br />State <br />co,• <br />ZIP <br />c s- 31a—i <br />Phone <br />2- OCI 443. o SLO S l <br />Pherne Email <br />--WY\4:7,0/1 EAT- ep rneir-lkeccx • c) IbU <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 Assigned To Linked FA ID <br />Date PE Fee Record Number <br />rtfras aves- ---ic4 f yik Au_ <br />?Rit40/915