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0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor <br />If contractoPAYMENTlicense <br />REcEnigp <br />State <br />JUL 29 <br />0 Architect <br />number First Name Last name <br />Address City <br />Phone Phone Email 2024 <br />SAN JOAQUIN CouNlY, <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,HeCniptiojkAT • d/or project <br />ENVIRONMEN <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as ide tified 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 all SAN JOAQUIN COUNTY Ordinance Codes, <br />141—e111A-- <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />RIPROPERTY / 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 />DATE: <br />7 - 24 -.2AI <br />fiNew Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name jeiaiD c ' A() 77-e-72 L. G,C, ---P e DCZ.16lieTs <br />Site Address City /6 7 8 3 _.ay 6.t do AO. 1.47-Ar---ko p <br />State C44- ZIP <br />9 5 86 a <br />APN Supervisor District <br />Type of Service <br />Requested <br />rApplication for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments CFO- ClasS A <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 />ID Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name /(40/24Lift, Last namep,b it) If contractor, indicate type and license number <br />Address <br />/4 7 g3 612A-yse V RD. City 644,-,A oe cols. State ZIP q, r <br />0 a a 6 <br />Phone <br />. 2 o 4- 4 87- Stgr«.2 <br />Phone Email Akikg.'"oit, ket07747 —as A:Mr/I,. <br />@., \,ertht , <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect le <br />First Name Last name If contractor, indicate type and lice <br />.., <br />e n ber <br />Address City State 21 IP sc <br />Phone Phone Email 1 <br />Accepted By .1—c Assigned To <br />K L rg,V01)3 <br />Linked FA ID <br />Date .7 ei i. .4.. y PE l COOS Fee j in% - I <br />4/53S01 <br />Record Number <br />APa4007q9 <br />0 Cash 0 Check # izr Confirmation # i ri-4 7 Ivqj <br />Payment <br />Received By <br />Rev 07/10/2024 <br /> <br />roll).- 7