|
,hatilling Party ,..aracility Owner ..ncility Contact .$-Ptoperty Owner 0 Contractor 0 Architect
<br />First Name
<br />X14>cC-.,\'t r
<br />Last name_
<br />"V‘ Ktot_c
<br />If contractor, indicate type and license number
<br />Addr
<br />5
<br />
<br />tt 1 WitA nc_ )\-\)6-_- Ci ,,,c,bc_eiotsit State Cdc- ZIP
<br />q52-0-1 7,4451. 4515,1565sphoniciico 4:013 En4ac
<br /> LA •P VI 01C4Mgrika.C° i .CCie• _ri v s
<br />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 H RTMENT tru charges associated with this project or activity will be billed to me or my business as identified on this
<br />form.
<br />Bon at the rk to be performed will be done in accordance with all AN JOA IN CO TY Ordinance Codes,
<br /> DATE: 9 ll 2 pill-pp?...
<br />/PROPERTY / BUSINESS OWNER D OPERATOR / MANAGER D OTHER AUTHORIZED AGENTDVIr . FCA-C4 III se ifi.E7,9.4:•:•-=‘, -..."1 i
<br />ti,it. Apr,
<br />Title C.- t."I Ve
<br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign Is required C: ,
<br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, heitrin autilOri* thyn,
<br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIROMfoNTAL HEALTH <Urn
<br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. - •-10,41r, k'j,,, sd i !IN
<br />v I,RoA,..9ULiAj,
<br />I also certify that I have prep
<br />Standards, STATE and FEDE
<br />APPLICANTS SIGNATURE:
<br />San Joaquin County Environmental Health Department
<br />Application Form
<br />Facility* Name
<br />5a0t c) Ohl-QQ ht---1, '0C--17.4- Cot-
<br />SiteAddress ,---1
<br />t•5‘ -rPcc-irtc_ me
<br />City
<br />itz.x.Aczt..1
<br />State
<br />cik- ZIP 152_0-/
<br />APN Superviso!ftrict
<br />fl-QC1.-4 COAb‘ii,
<br />Type of Service
<br />Requested
<br />yi Application for 0 Consultation
<br />Operating Permit
<br />0 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 />_.Billing Party ,..1a1'acility Owner ....lagracIlity Contact ....ha -Property Owner 0 Contractor 0 Architect
<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 CI 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 Liu adk , Assigned To Li p44NTAL Linked FA ID '' rt-r1T N
<br />ateC1 7)94 rk-) ° IVt't).'
<br />Fee t., 1
<br />1 t
<br />li_4a., Record Numbe Ra4,205 13
<br />re 09,10:twoilzi2f
<br />f/7? ce//e,e ,
<br />?Y0,1-1 00312,
<br />
|