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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 applic n and that th t be performed will be done in accordance with all AN JO UIN COUNlY Ordinance Codes, <br />APPLICANT'S SIGNATURE: DATE: 1:3 Standards, STATE and FEDERAL laws. iryj r ; <br />NVINENI <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 />2 <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER VoTHER AUTHORIZED AGENT <br />San Joaquin County Environmental Health DepartmeTENN AUG 14 <br />Application Form <br />NT <br />Facility Name pjoir) appetii.... ,'ALTi-i D ' ,(CNIA e,c, () Less 1 on E PA R Tm <br />Site Address3 (9 0 1 tp etc I f e", Citcyssica.+Dr..) State State <br />cot. ZIP q 5211 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />KConsultation EChange of Owner 0 Repairs or Remodel 0 Other <br />Comments • <br />Wing D JAY eon ZS 11). OS Fi'DM lini Veils' ti) b - +h Paei 11-''-& <br />If mobile food truck or - <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />ty(131111ng Party 0 Facility Owner TKFacIlity Contact 0 Property Owner 0 Contractor 0 Architect <br />v Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name SonnLID. Last name (1. c., <br />.7). .0 <br />. If contractor, indicate type and license number <br />Address t 01 'Tres 1 c1err. Di. citys_ofcn State rrAi , ZIPDI2.1 1 <br />phone 0.3scaticine <br />(2Cq) <br />Email 3onnia_.e.osia2Pc0C6DnapPti-ii-ocom <br />0 Billing Party 0 Facility Owner )(Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name 0f., <br />,..2. 1 Last name u flAon I senz_ocle If contractor, indicate type and license number <br />Address 4, <br /> <br />01 Pres i nis Dr. Citysix, .te, r <br />State n ry ZIPq 62 1 1 <br />(tfic16) i4100 ..xclo phone 1.401 , 10/40 <br />EmaSP fa. nichsenwd equip 0 aa-ixn 0 PPeff t'.0(ern <br />0 Billing Party 0 Facility Owner 1E/Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name n n -, 1 Y ICU 1C:0 Last name io al VW c If contractor, indicate type and license number <br />Address OD') Pres (dents Dr, atsfccitfon State , <br />ZiPg 621/ <br />Phone \ <br />( 05 0/D1 2190 <br />Phone Email <br />... arCo.a.ltiarodo e at:Felon appeht. corn <br />Accepted By <br />Datesfir <br /> ilyifiE <br />Assigned To hz u ft? c ,.. Linker4 606 ., a3.__3_ <br />a. Pee jy1/9 <br />P.- - 1 ,./.." <br />80 0 <br />Record Number <br />SR2.40XnbcA <br />21°b ezeimutt tov-18ip 44°1 aa— <br />oviRtAttui ovorws1149 aurlq- <br />Pi2.01031