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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 t ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL lay4s41 <br />APPLICANT'S SIGNATURE: ke-c(CL <br />5 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addressawb authorize t 40 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONM 64/11-1 <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. heolo. ROAri,COUN <br />' N OgA_ 14J <br />DATE: t — 1 <br />Rea <br />0 PROPERTY/BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />Title <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required An/ 1 <br />k/ 0 New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility fsu <br />Vel--Mtr d ON(1404 S-40 C k .4 0 V\ c A q 2-() -4. 4f <br />Site Address <br />1-0 A7' ak V 1 Vreeti4 \i`j 4 \I Ai (I <br />City State ZIP <br />APN Supervisor District <br />Type of Service <br />Requested <br />pplication for )< <br />0 rating Permit <br />Xonsultation 0 Change 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 />›E Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />'-'k re,-)(Arci <br />Last name <br />ck <br />If contractor, indicate type and license number <br />tlst AAs <br />%\3Y'C \11/4) AN /0 akv <br />City, <br />SA-6c-k-ke ti <br />State <br />ki it. <br />Phone <br />'C.7,0q 41 s 3 -;,4s-3-' <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 State ZIP <br />Phone 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 State ZIP <br />Phone Phone Email <br />Accepted By i\. Assigned To 6 Linked FA ID f A 4w 0)/ilt4 s 3—÷.... ivi- <br />Date - <br />\--1 S .-- 1 R OS <br />PE Fee <br />11 2 --- —. Ita•.____ Record Number , . , ...e..., <br /> <br />AP251)I L I 5 <br />0 Cash 0 Check # 11/Confirmation # (-1/..ii-f2.01 (v2.4 Payment <br />Received By <br />Rev 07/10/2024