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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 COUN IY Ordinan <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: e /Ye v ck„, /3 0 ,4 , DATE: <br />Title <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required J0,1 Q‘ <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, heiektrw no.,, Cotrre., E.,,., <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL Atm E p ,,E /11 TA iv Ty <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />'''CIVT <br />0 PROPERTY / BUSINESS OWNER <br /> <br />/OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />(01//6/2 -i- (i/t) <br />JA*-- <br />SAN 2025 <br />-PP052(009-2 <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Tahoe's Pizza <br />Site Address S <br />1205 Plaza Ave. unit 7 <br />City Escalon State CA ZIP <br />95302 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation ffil 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 />C5I Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />2 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Frederick Last name Bonilla If contractor, indicate type and license number <br />Address 1913 Tioga Pass Way City Antioch State CA ZIP 94531 <br />Phone <br />925-754-6848 <br />Phone <br />gjc-1-2-4. 11 a o /1Nonillfc©gmail.com tahoepizzaescalon©gmail.com <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 1 c- ^ Assigned To /? 1 N 7-7" Linked FA ID <br />/ /. ‘410 <br />Date Fee PE Record Number <br />SR2500,1 - 8-4 <br />ec7i*: rv-ii-robt Ig`199w9c1