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0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />anakAtIVIENT <br />ZRECEIVEDIP <br />MAY 0 8 <br />First Name Last name If contractor, indicate type <br />Address City State <br />Phone Phone Email <br />. <br />SSW* 2024 <br />Or IAA ID: SAN JOAQUIN r, a i miry <br />ENVIRONMENTAL <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge thattliAlinleapiwaimtNT <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 JOAQJIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL lawy- <br />C/ <br />y-fe.,,,_ <br />APPLICANT'S SIGNATURE: /71/ riZe."1"1/ DATE: . <br />E4ROPERTY / BUSINESS OWNER o 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 />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name r a 4-n / 69 >/el /- 2 0 71--Ef ,e <br />Site Address City <br />/ /' / 7— i 5- . n / .7r7 I I— rit-0(7/erof., <br />State <br />(/- <br />ZIP <br />QC---.0 C <br />APN Supervisor District <br />f / <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />.4441/faialA ErChange of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />2/ r 7 e a 9 7 <br />VIN-2- r9'8,e)lx-AiT47-- 2-Y6: <br />ContactTypes <br />required <br />El Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name_ / ii <br />V / ovr- ilz A. ,-7- <br />Last name') If contractor, indicate type and license number <br />Address <br />/7 /145 P7-1cA (-4 f-C7 7 i 7i-- <br />City _ <br />)'Zi7"1 <br />State- <br />', ,/- <br />ZIP <br />Phone <br />-0 - <br />Phone Email <br />ID Billing Party lFacility Owner <br />_ <br />0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name . <br />/ / <br />.7 1 5, /ft? --Si- <br />Last name <br />Lb/viol/ La. 1-er i IA5 1 riAC 14 <br />-4-etwitRetorrinflieate-type-ancl-Licause_aumbez. <br />, Address <br />Kv.g7 ftr -Z--- , t; /-. .6.' 4 ) 0 r <br />City . <br />71 a 7 Cer°14" <br />State <br />'/A_ <br />ZIP <br />9C7-... r <br />Phone <br />709 <br />Phone <br />— 2 98 cij <br />Email <br />/ K . <br />Accepted By <br />Date <br />5 - a 4- <br />5. .'2)ailooLkin <br />PE <br />Assigned To , ) 1 . _ .., , <br />K, . L , v-.. i (Axes Linked FA ID <br />Fee <br /> a i <br />Record Number <br />.1 <br /> <br />5Ra4®0145 <br />sC4c1