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0 PROPERTY / BUSINESS OWNER <br /> 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />BILLING ACKNOWLEDGEMENT: I, the unde <br />specific ENVIRONMENTAL HEALTH DEPAR <br />form. <br />I also certify that I have prepared this ap <br />Standards, STATE and FEDERAL laws. <br />/AN*0LICANT'S SIGNATURE: <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 ad <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY E <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />d property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />T hourly harges associated with this project or activity will be billed to me or my business as identified on this <br />to be performed will be done in accordance with all SAN JOAQUIN COUNISAdinance Codes, <br />)‹-TE: C, I /Z. INEArr <br />EnteD <br />-IL.'" 9 2024 . • QftityiAlazZ <br />at <br />0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form ipeol(00141-5 <br />Facility Name n <br />Site Address <br />2,4 0 5 Pa,C1 -(., i\-ve- <br />City <br />'S+Dci(i7, A *7" <br />State <br />CA r- <br />ZIP Is z. 0(i <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation . 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />Lrcense 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 />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First I , <br />Last name , , <br />7-- ciApo d I <br />If contractor, indicate type and license number <br />...Address p (p g,x jois .7SiVn- c <br />I i lik at <br />State ›- CA <br />ZIP , 9 c --si <br />Phone <br />72-0C1 - uf L,L-161fr <br />Phone 1,..!mail , <br />rotAne11-abkV(22A1$2. 0 cobk.1, Lc.././1 <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 ,.. <br />C-a Ifft./ e..c I.--0 <br />Assigned To <br />I3,, kaP-* <br />Linked FA ID <br />f A eaD 1510 <br />Date <br />—VI '- 2A- <br />PE <br />I 609 _ <br />Fee <br />t (p 7--- <br />Recg_rti Number . <br />5ViLte(0 25-3- <br />(9(0124- *Liar p6t(1L6 <br />A ciaiiket4t; iwg[201- <br />16-