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BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge thateAlfaltI8PAR°11tNT <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 -AN JOA9IJIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL layvy <br />APPLICANT'S SIGNATURE: efi C/7 DATE: 2-id( <br />1/PROPERTY / BUSINESS OWNER <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 />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />ENVIRONUFNT <br />0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />San Joaquin County Environmental Health Department 64coo5i10 <br />Application Form A-17 2LiOCI1 /411-q 4242*°23' <br />Facility Name 4 . <br />/ Z 0 74-E•5- <br />Site Address <br />/ / 1— S . Zn/ i '), ; I-- <br />City <br />Pr/C/tRY, <br />State <br />C A <br />ZIP . <br />9r20 6- <br />APN Supervisor District <br />/ . <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0(CcifiVtliaek GZhange of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />4/ rz ea 97 <br />VIN <br />-z. r? 8 ,e -1 x NI cl-- Z6 <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />R'Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name_ / 1 <br />1.7 / (tif7K g arn i )-4'.."1"-- <br />Last name') <br />1(4 1'7 1 / )-e-7.--- <br />If contractor, indicate type and license number <br />Address /2 /1-15 r7-1,4 (V, "f ,.7 rfr <br />City _ <br />),c''-( <br />State-ZIP1. <br />,b. -"---.7,.-- ,-- FAone _ <br />1-0:7 -. <br />Phone <br />Ze , •-g7 7 ) -''l. <br />Email <br />0 Billing Party EfFacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />/9' / 1 5; tf.t, / I: w/ SIC" <br />Last name <br />i OY1 La. -1-_,r i iAl TrrAC I.< <br />- , • <br />C. e'- <br />Address , <br />K.c-./ Pe...A/Lc , t - I .7. C. 1 9 CD <br />City , <br />r/vCe7-07"-- <br />State c-24 ZIP 9i-7,, r <br />Phone <br />7‘19 — <br />Phone <br />2 98 ci <br />mail <br />g. <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />anoRAVIVIENT <br />ZRECEIVEDIP <br />MAY <br />First Name Last name If contractor, indicate type <br />Address City State <br />Phone Phone Email <br />. <br />sski-o-, 08 202/I <br />4 o r 10.1 ID: SAN JOAni HAI nrii ikiT, <br />Accepted By <br />k 5 r) <br />Assigned To <br />- in - • ir k L , ,(k es Linked FA ID <br />Dat <br />e <br />Record Numbers <br />Ra400145 <br />417ef. op