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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 app ication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />@-40-A-ZtA-4 APPLICANT'S SIGNATURE: <br />0 PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br /> <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 /> DATE: C0 11 <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name hy\ <br />•+6 i 4-0 i+e-ChOS COn <br />Address Site Address <br />I; ',..:-.15_, 2•\ IS- V5L _ iLlKe- ..> <br />City <br />STOCAC-PY) <br />State <br />Cii- <br />ZIP <br />Cigt9-1 o <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 ., i <br />kt <br /> <br />1\ -•) -\ C.Ckl--4 .2_ 1-277-tra C..(c'S -N A A <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />JON 0 7 .) , ,f).), <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner <br /> <br />- Ir( <br /> <br />0 Contractor pz.,?,NMEJ4iftrAyt <br />L"MIT/SC‘ <br />, , <br />tlEkrk Rifin - <br />"CO <br />rilling Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First CZ. <br /> CUA-Ad <br />La t name <br />CO (3-t -IE <br />If contractor, indicate type and license number <br />Address <br />Sg-S L4) • \ ILLS 4r4tir <br />City <br />CaCCH—DrN <br />State <br />C44+ <br />ZIP <br />9 Soi b <br />Phone <br />aoel(p9-6 -0-i <br />Phone <br />co <br />Email <br />l; I kcAo V1 @ L , <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor ID 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 Assigned To i Linked FA ID <br />Date <br />I ' <br />(. ia•C.A-- <br />I PF Record Fee 1 g6 — Number <br />Li <br />RZ2.1--1 O)2•3