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ed will be done in accordance with all SAN JOAQUIN COUNTY Or nance Codes, <br />BILLING ACKNOWLEDGEMENT: I, the under <br />specific ENVIRONMENTAL HEALTH DEPART <br />form. <br />I also certify that I have prepared this ap <br />Standards, STATE and FEDERAL laws. <br />014014,1041Wil <br />0 PROPERTY / BUSINESS OW <br />a.nd that t <br />ed • . .erty or business ow r, operator o uthorized agent of same, acknowledge that all site and/or project <br />ourly charg assoc ith this pr ect or activity will be billed to me or my business as identified on this <br />_ <br />Pr Air 4firr <br />o ER , 0 m , 0 OTHER AUTHORIZED AGENT <br />YMEN <br />0 New Facility til/Existing Facility 4 <br />San Joaquin County Environmental Health Department <br />Application Form FRosLitsW2 <br />1°1M' Happq Bay act,- <br />MIMI I 304 E. I-I anim eR L. 5Y4.— r <br />riCity, V <br /> Skid: bo-n 1 °ate C q 5g 10 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation E(ttoli— e,qtql 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License 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 />Elf iattAfipwjleri sq0110i01104 0 Property Owner 0 Contractor 0 Architect <br />111111*; • a ,,,,,,)-vk <br />If contractor, indicate type and license number 1111:11/ 1 <br />illil lin o C 61710( ,.)\-v4--61,0c-C Lh 41100 <br />-ILDrk 7on °IP C A 9Th <br />1..oko 6-. -Nkl,e1 <br />Phone <br />\., \ 1.111.1-(40 bei_Caalia6 I. (9 7rIC 4- I f - '42 i-K 7 , <br />L./ <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 />If APPLICANT is not the BILLING PARTY, proof of aut orization to ign is required T 1 1 2024 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addresqoVittwthorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRCiriefriMitril-Coi ik ,, <br />Accepted By 5 B Assigned To <br /> <br />v I <br />Linked FA ID rmazac..0 25 <br />Date <br />ioll[(2/-1- <br />PE 1(002 Fee <br />ti 1:7 <br />Record Number 5Ra4005(98 <br />Title <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. eALrFiop,PENrAL <br />Rev 06/12/2024