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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 appli ion and <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / 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 />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />the work to be performed will be done in accordance with all l fokr AQUIN COUNTY Ordinance Codes, it <br />DATE: (6 If 1068-21-tq <br />New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name T-e <br /> Arn0 OrSSei4S <br />Site Address ! 0 <br />[4 MeAt-, v0Or nf Of <br />cits*it State 04 ZIP ciS 263 <br />APN Supervisor District <br />1 . . <br />Type of Service p Application for <br />Requested Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />. • <br />Comments Myv C 4=-0 cl-rAss 4. <br />If mobile food tru k 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 />(1411ing Party )Wacility Owner 0 Facility Contact 0 Proper y Owner 0 Contractor 0 Architect <br />First Name [ °Lod i (3‘ Last name V I aiencia If contractor, indicate type and license number <br />Address <br />loiLl Nelbouine cwt City S+ocY-Ion State ZIPtA <br />q5 26_3 <br />Ph <br />P 4501.603571 <br />Phone Email( 14,1/604.(bil <br />75 e 9 titctika IN <br />o 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 RECEI ED <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contrac <br />AUG 22 ?elf chitect <br />- . <br />First Name Last name If contractor, indicate type and license.n.urfier <br />ENVI1ZONN1EN IAL I-ILALI <br />Address <br />, <br />City State Dl l'A Ill N1 L1 <br />Phone Phone Email <br />Accepted By\ <br />( :CtARALec <br />Assig ,a"o 1 . Linked FA ID <br />Date PEPE Fee <br />9-1-:' <br />Record Number <br />RP214 anc(2-8 <br />)6 Cash 0 Check # 0 Confirmation # <br />Payment <br />Received By <br />Rev 07/10/2024 <br />9._11 051-