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Rill MC; ACKNOWLEDGEMENT: I the undersigned property or business owner, operator or authorized went of same acknowledge that all sitd renieLWADIn <br />pp, , co uN <br />tV TA specific ENVIRONMENTAL HEALTH DEPARTMENT hourly chargesassociated with this project or activity will be billed to me or my business as identifiZ TiSiit14,EP,4 NEN <br />form. <br />, _ <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 la <br />APPLICANVS SIGNATURE: <br />ra/P ROPER TY / BUSINESS OWNER 0 OPERATOR/ MANAGER 0 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 />7 I (Ati- DATE: <br />0 New Facility i;fEXiSfirig Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />E.I ar, r eiCirloi. t, CAN+ tick ... ---- Cc '\ r-\ 0\ -r• Cc\ r \—\ r <br />Site Address <br />16`1AS S hAv I etiN rct 0 1 <br />City <br />WI\ CI) <br />State <br />CA <br />ZIP <br />cis330 <br />APN <br />V-11- 3, lif)-_le <br />Supervisor District <br />-S <br />• <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consuttation ' El Change of Owner Aepairs or Remodel 0 Other <br />Comments <br />If mobile food trucit or <br />pumper truck <br />License Plate Number I VI <br />Contact Types <br />required <br />0 Billing Party 'Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party (Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />00ret0 <br />Last name <br />%.1 isrerc2, <br />If contractor, indicate type and license number <br />Address <br />t q %06 Cdcisua ci <br />city i <br />iliK4 te.p, <br />State <br />CA <br />ZIP <br />9S33.:3 <br />Phone <br />'c 1C.) 4 zs_ act96 <br />Phone Email <br />irrro ACcirti i nes . (01--, <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 />11/- <br />2024 <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />PA14 Name Last name <br />C <br />First if contractor, indicate type and license nurykyrE. <br />A <br />Address City State ZIP <br />406 Phone Phone Email 0 <br />Accepted By , Assigned To • ^ L . r.\\w. (E3 r Linked FA ID <br />c'" F (N 00 \CI S 1 <br />Date PE <br />\ <br />Fee Record Number <br />Icec ter- 44- 4,s74..y) <br />W052,1531-