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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 law <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: 8/19/2024 <br />51 PROPERTY / BUSINESS OWNER r*OPERATOR / MANAGER l OTHER AUTHORIZED AGENT CEO <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 a <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN IY ENVI <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />hereby authoZ210 <br />)HEALTH <br />kcl New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Zingeye , <br />Site Address <br />5444 Saint Andrews Drive <br />City <br />Stockton <br />State <br />CA <br />ZIP <br />95219 <br />APN Supervisor District <br />Type of Service <br />Requested <br />R Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />t\)e,..._; Co clas% A <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 0 Property Owner 0 Contractor 0 Architect <br />51 Billing Party 12 Facility Owner 9 Facility Contact Q Property Owner 0 Contractor 0 Architect <br />First Name <br />Tobias <br />Last name <br />Handschin <br />If contractor, indicate type and license number <br />Address <br />5444 Saint Andrews Drive <br />City <br />Stockton <br />State <br />CA <br />ZIP <br />95219 <br />Phone <br />404-394-4479 <br />Phone Email <br />Zingeyeforce@gmail.corn <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 Vidal Pedraza Assigned To Lydia Baker Link FA 'Do 12941 *4 <br />i .9 4 19 <br />Date 8-19-24 PE 16oe Fee <br />$ l L,.. (i_O <br />k- pc....1...-.et‘, - tANfitrat.14..r1 ,--- c d Number <br />11)9\9iv03‘g <br />T4) -e 8r111//1— <br />Rev 06/12/2024