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is <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all sit.+ <br /> 16,ti'V 44 °UN Ty specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifi ... thlEPA ,T,AL form. fvIENF <br />I also certify that I have prepared this applicati n and that the work t e performed will be done in accordance with all SAi JO i UIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: . <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANA ER p OTHER AUTHORIZED AGENT Axvis4y D;y-e_.c..4 0 e a- <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 />(_) <br /> DATE: <br />cpcmcin'0"5 <br />A New Facility [Y Existing Facility <br />San Joaquin County Environmental Health Departme‘t <br />Application Form er2_ 2L•oo Li3o <br />I acility Name <br />one. Lathrop South <br />Site Address <br />16948 Harlan Rd <br />City <br />Lathrop <br />State <br />CA <br />ZIP <br />95330 <br />APN Supervisor District <br />Type of Service <br />Requested <br />El 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 />License Plate Number I VIN <br />Contact Types <br />required <br />IS Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />kJ Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />Soot Ti3ottc4 i‘ il COC.i./ <br />Last name <br />i c C.. CP-V Eeit4 CCA,41‘P i/ <br />If contractor, indicate type and license number <br />Address City <br />5fk c.4Okt <br />State <br />c• <br />ZIP <br />`152.13 - cfa 3c P5 ex,x zfr3o <br />Phone Phone <br />(2043)q -- liV 41 <br />Email <br />5Jco e — cApe sjcoe . ki c+— <br />o 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 nurntayi yl <br />fil.0 <br />i g <br />Address City State ZIP <br />Phone Phone Email Ocr 23 <br />SA A, <br />Accepted By Assigned To i t___I A t&a,r-cc Link <br />edf-F AA 0 0 °Q (t) C 3 e--- ----ws-a---/ <br />Date PE Fee z_0-2.) Record Number <br />SC.2.4 (ticL5C2- <br />Payment <br />Received By <br />0 Cash 'Check B /0‘43gy 0 Confirmation fl <br />2024 <br />Rev 07/10/2024