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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 application and that the work to be performed will be done in accordance with p11 SAN JOA IN COUNTY Ordinance Codes, <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br /> <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 />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: —43 <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />d c <br /> --E:-.4,,,,ra„ p fon u e- <br />Site ,Mc'fess Cit\r_ State <br />Q.AL '43 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner <br />I, r <br />0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />Li en Plate NumbeL <br />I 3C1 —Z. i <br />VIN <br />ICC, TW\C, \tkCi g-CA '- I b SI° 1 <br />Contact Types <br />required <br />OBilling Party 9 Facility Owner 0 Facility Contact 0 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 ame i crinr <br />IV <br />Lastname <br />-__Spiftf7(1 <br />If contractor, indicate type and license number <br />Address n , c_t) is..cacocl. -,,k- ...K.‘c)ft, <br />City State <br />OA <br /> <br />-2'131c174).4&mr <br />J‘ <br />Phone Email <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 Stat ZIP <br />Phone Phone Email <br />\ \\ <br /> <br />\i\ <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner NI ConiVtNr 0 le z--... • .. —.. _ t ArchikECEIVE <br />First Name Last name f co tra , indicate type and license number <br />MAY Z 0 20 <br />Address City \./ State ZIP <br />SAN JOAQUIN CO <br />ENVIRONMEN1 <br />HEALTH DEPART Phone Phone Email <br />Accepted By ...._ <br />F / 74?,t,f t <br />Assigned To , <br />..F ° /?L 4 ( 2_ <br />Linked FA ID <br />Date <br />‘7201 VI <br />PE <br />/ " <br />Fee it- , <br /> <br />LN / o1 1).14 gel qU't 1.3 <br />Peewit atrnber <br />2q. /I/ <br />1(11) CetIL 04-- VISA -it/Z1?L33 q- 6-72,./)-1,24 <br />vIv ci)4)/liv , ),/ <br />omflitiP KIT <br />24 <br />NTY <br />AL <br />ItiENT