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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 application 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 />APPLICANT'S SIGNATURE: <br />OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <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 />)4,PROPERTY / BUSINESS OWNER <br /> <br />-11tX do <br /> <br />DATE: <br /> <br />II New Facility Q/Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name ,--) <br />\ "7--"Ze.. QA‘is. it (ke\ <br />Site Address Sao E. --roic....,dtc. A. .1 C._ <br />City .A <br />t'l c•fx\-eCc <br />State <br />CY-\ <br />ZIP <br />C t S-33 6 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation ' AChange of Owner 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 />96-Billing Party pi.-Facility Owner ' kl<acility Contact 0 Property Owner 0 Contractor 0 Architect <br />ID Billing Party Xi Facility Owner XFacility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name n . _ 1 , tiitAid ) <br />rir;\ kc. rko k_ <br />Last name <br />Cke_in <br />If contractor, indicate type and license number <br />Address <br />6031 LA,,,?rcs-t 0( <br />City -StIc Grove_ State <br />CA <br />ZIP <br />elf6Dtt <br />Phone <br />CIIC —el< -4136C <br />Phone Email <br />DAval cke_4•_ I la et I-N4 , Cove\ <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 Architia44 ya. <br />itg 47EN <br />First Name Last name If contractor, indicate type and licens Crielv <br />0 JU <br />Address City State ZIP i2 <br />L . <br />8ANJnA, 2024 <br />EjVil—wU/N Fit,fit &Olvm couA, No 4r 7}' <br />Phone Phone Email <br />Accepted By s. sdewaLA___ Assigned To &I n.1 .f.— Linked FA ID <br />Date 7-1a-cM <br />PE <br />U009. <br />Fee <br />ii- <br />Record Numbe <br />6 R 2400 g q ci <br />? ifr17.2,00 . IF4-651 3-0 <br />PRO ( (411 S