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'IE AL nKb, ENTA <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site andfori4oiTen4EN <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 ap cand that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. ae;iif <br />APPLICANT'S SIGNATURE: <br />14)PERTY / 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 />'r- <br />DATE: <br />0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name E L 1 A 1 <br />0 r Y t tGt -1-6 c 0 <_', '-B (2-(-2_,a I. 1\-Aoisc_05', <br />siteuldt1 to i i <br />1\ -k arCIA- 6( 442. <br />City <br />'5—cc 'e_-401,1 <br />State <br />CCt <br />ZIP <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 1;Khange 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 />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />"Billing Party rFacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />P <br />A . , <br />k 1 \ efitA <br />Last name() <br />)cimvezirel ep 16.0 <br />city , <br />, <br />If contractor, indicate type and license number <br />Ad cy4s.i, <br />L, 3 2-' 0 kifiVc p 0 i ii-t, z_v, Mele_sZp <br />State e4 ZIP .ns,.. _ <br />i :7S .S' <br />Phone <br />'l NbrIV--0 <br />Phone Email <br />01 i le-60 te-vi A fe,t 00a <br />0 Billing Party 0 Facility Owner Sit/Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First fame <br />V/ ,5 <br />Last t)e <br />....)/()4 Ve---2e4 <br />If contractor, indicate type and license number <br />A dress <br />a?_7•02• /-c7-1) pc', Ai-r- 2-41 <br />City / State ZIP <br />Rhone <br />(5/ 0 )3 51-10a <br />Phone V Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />PAYmp ik , <br />First Name Last name If contractor, indicate type andRee"la,,loer-- i If <br />L't/ VEL <br />Address City State ZIP OCT 0 1 2024 Phone Phone Email <br />SAN JoA Q , „ <br />PNVira,'N COt IM . . ,.. <br />Accepted By Assigned To t 3 Linked FA ID <br />FA 060 1 5 (05 <br />Date PE <br />(). <br />Fee <br />-5 I -7 ii <br />Record Numbers Razi_o i?), 5 50 <br />?L /72.ap <br />Rev 06/12/2024 <br />CoH 1 4 5 <br />PRo1p-2352.