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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 applica ibn a cl.-the e ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, _ir <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: NuV - 22 - 2O2Li <br />0 PROPERTY/ BUSINESS OWNER 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 />g New Facility 0 Existing Facility, <br />San Joaquin County Environmental Health Department <br />Application Form (Ne€c\vz. <br />Facility Name <br />CHAIFEE Lt-C. <br />Site Address State <br />? <br />c A City <br />W TR/ <br />ZIP <br />ciS3-i <br />APN Supervisor District <br />Type of Service <br />Requested <br />p Application for 0 Consultation <br />Operating Permit <br />0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />3e,03 co cit.vcc.,11 (applicit-floo -eiricuied fb J-e-Pr C,) <br />If mobile food truck 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 />tp Billing Party GI Facility Owner k Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name , <br />t- A 1,1 vi E_.. Ni <br />Last name <br />M oEE•t\i <br />If contractor, indicate type and license number <br />Address <br />521 P 'L -t RIO s-r ILE t--,---r <br />City <br />-Tv- Acl <br />State <br />CA <br />ZIP <br />61 C3 -tlo <br />Phone <br />SIO - ci 9 -013c <br />Phone Email <br />cht6f ee ,‘,6e 9 m ci; I .. ( 0 ryj <br />0 Billing Party 0 Facility Owner CI 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 <br />P4 v. <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor RIZ eien7 w I <br />ED <br />First Name Last name If contractor, indicate tyriWkiltlitt <br />SAN <br />umber <br />Z024 <br />Address City State <br />EAAN-114 HEAV,NMENTAL <br />1.1fr.., <br />C°UAITY <br />Phone Phone Email ART"" <br />c P A, ENT <br />Accepted By <br />3c.f 4s C. <br />Assigned To <br />JeFc C.- <br />Linked FA ID <br />2_ : Date <br />12A Illi PE (40Tilb I <br />Fee <br />I BG $ <br />Record Number <br />LI P2-tithl:52-0 <br />0 Cash 0 Check # /Confirmation # / q i 3 3-4-- 1 3-6„ <br />Payment <br />Received By al <br />Rev 07/10/2024 <br /> <br />MS 00221-*