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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 />Standards, STATE and FEDE a <br />I also certify that I have prepared this application and e work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />APPLICANT'S SIGNATURE: \&-/ DATE: 5 -224 <br />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 />0 OPERATOR / MANAGER <br />0 OTHER AUTHORIZED AGENT <br />so, <br />San Joaquin County Environmental Health Department <br />Application Form <br />1 Facility Name (Qs cut <br />Site Address 5 0_ N. vv..._w\_\_.* 9..8 <br />citY‘..,,v\a„,.., State ZIP <br />APN Supervisor District <br />Type of Service <br />Requested <br />,Application for <br />Operating Permit <br />0 Consultation 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 />al Facility Owner <br /> <br />'Contact Types <br />required <br /> <br />0 Billing Party <br /> <br />0 Facility Contact <br />0 Property Owner <br />0 Contractor Architect <br />0 Billing Party 9(Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name s <br />'‘C- \ WIN1.)L\ V <br />Last name a <br />Ickveica If contractor, indicate type and license number <br />Address <br />le)-- N) • Q.C1 le.i..kj%—t"-t--- <br />City <br />U Y\CA.A....YN <br />State <br />C_A <br />ZIP <br />ot 72_3 Cop Phone <br />001 - lic(P - MSS Phone Email <br />1or tveif Movie, <br />0 Billing Party 0 FaciRty Owner <br />,.., <br />0 FadlIty Contact 0 Property Owner 0 Contractor Sect <br />I First Name Last na e If contractor, indicate type and tic, se number <br />Address <br />I Eli <br />City State ZIP <br />Phone Phone <br />\ \ I)) <br />0 Billing Party 0 Facility Owner 6'Faci ty rika 0 Property Owner 0 Contractor 0 Architect <br />First Name ame If contractor, indicate type and license number <br />Address <br />Ak <br />Oty State ZIP <br />Phone Phone Email 1 <br />Accepted By e, A4 ri (2-o 0E <br />Assigned To c . ay (I P.--0 <br />Linked FA It ail t <br />bate , la-e(20c2 it 1608` , 00 'te im. Rec?idrnte:r3.0 <br />PN <br />46f€ a etched avy 1,4u ttct ôi pc., Po <br />ci--21Y°Yg