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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 /> DATE: <br />PROPERTY/BUSINESS OWNER CI OPERAT / MANAGER El 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 />San Joaquin County Environmental Health Department <br />2024 <br />SAN JOA Q1J <br />AUG 2 1 <br />OUNTy <br />TA L <br />MENT <br />0 New Facility 0 Exist/a/WI/WENT <br />RECE/VED <br />Application Form <br />'— VIH Facility Name Ha& CDNM Et Angry chickz Nashville Hot Chicken 11 DERAR <br />Site Address_State 2431 Naglee Rd. Suite 7A City Tracy CA ZIP <br />95304 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />El Consultation Vhange of Owner Nit 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 III Property Owner 0 Contractor 0 Architect <br />El Billing Party CI Facility Owner 0 Facility Contact 0 Property Owner I=1 Contractor NI Architect <br />First Name <br />Gary <br />Last name <br />Rogers <br />If contractor, indicate type and license number <br />Address State <br />7940 n maple ave. #103 telsno CA <br />ZIP <br />93720 <br />Phone <br />559) 203-9405 <br />Phone Email <br />Gwr25@yahoo.com <br />0 Billing Party vOr Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor El Architect <br />First Name <br />David <br />Last name <br />Mkhtaryan <br />If contractor, indicate type and license number <br />Address <br />15301 Ventura blvd bldg B suite 250 <br />City <br />Sherman oaks <br />State <br />CA <br />ZIP <br />91403 <br />Phone <br />318) 5545774 <br />Phone Email <br />David@angrychickz.com <br />El Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner CI 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 4 <br />(7-- Assigned To Linked_ELID <br />c o l <br />Date PE 1 / Fee i . 2_cyo Record Number <br />sg 2.401a) Lk- k(D <br />0 Cash 0 Check 4 Confirmation 4 13- 4,:>6168" b7 6 Payment <br />Received By <br />Rev 07/10/2024 <br />CoAX tg(oeic -9() <br /> <br />\)R052(0(-19-