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DATE: <br />Title <br />Francisco Ruiz Linked FA IDVidal Pedraza Assigned ToAccepted By <br />45yh-1601 537 Record NumberPEFeeDate12/31/25 <br />paid wnwPayment 213503152 <br />Rev 06/12/2024 <br />JAN 0 5 2026 <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 />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />RECEIVED <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 <br />identified 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:ISAACJUAREZ <br />12/30/2025