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First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />8/5/2025. <br />Title <br />Accepted By Assigned To <br />Date <br /> Cash <br />Rev 07/10/2024 <br />Payment <br />Received By1 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or <br />projectspecific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified <br />on this 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 <br />Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT’S SIGNATURE: _K^ DATE: <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER OTHER AUTHORIZED AGENT <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 <br />the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Record Number <br />Confirmation ft <br />.06 3 5^1^ <br />Linked FA ID <br />FA oo ST-FfT- <br />-'aie i i PE , , <br />fiX [(oO3 <br /> Check# <br />Fee <br />eZ>