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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 specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the wor Standards, STATE and FED APPLICANT'S SIGNATURE: 0 PROPERTY / BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. o be perfor d will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, U-11-1-2.9 DATE: El New Facility pif ting Facility " San Joaquin County Environmental Health Department Reee illeo Application Form Facility Name HZ,ZVVI&OAti vi L'OU/Vpy rei 14/3- gircl & ell t4 P014)- -r-it cos A fi -rm I- Site Address /_11L-4 0 S. 4\1(edi — Viiri s Citystv.4% j State CA ZIP EN7- q S2 0 Lo APN Supervisor District Type of Service Requested AApplication for Operating Permit 0 Consultation ' 0 Change of Owner 0 Repairs or Remodel 0 Other Comments If mobile food truck or pumper truck License Plate Number VIN Contact Types required ''Billing Party 0 Facility Owner acility Contact 0 Property Owner 0 Contractor 0 Architect 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last Eu s.etai 0 fitS\.){1 name ?On( e_ If contractor, indicate type and license number Address_ 640 reltecyk ci- Cit , State 04 ZIP el STI—Lo Phone 14 0 9 (#00 - G S2-1, Phone Email J 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email Accepted By dm Assigned To 1.,..6 Linked FA ID Date PE W°3 Fee u02— Record Number A.P2_44 upLi(i 0 .65 Pe 2-4 003W AIN 1 4 20, 4 sA A