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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 wit project or activity will be billed to me or my business as identified on this <br />form. <br />I also certify that I have prepare and that the work to b will be done in accordance with all SA JOAQUIN COUNTY OrdinanceCodes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />.of 21 102 <br /> <br />DATE: <br /> <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / ANAGER 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 />r 00061gs-- <br />izzz721- Rec ,'"EIVT <br />San Joaquin County Environmental Health Department civED <br />Application Form iki):Lq lidlisi,N 41,04Y3/ 2024 <br />Facility Na me 12/ef Ti pt.5 . H ENVIRON C°U pq ( 0 I <br />...,..,,„ <br />-4ALTi.i DpilliE fg7)NTAL <br />__ <br />Site Address tp 2 0 <br />S SA-CaiNtE Nip GT <br />City <br />/1)1) I <br />State cA Zy) c :2_1 6.Nr <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for 0 Consultation 0 Change of Owner <br />Operating Permit <br />0 Repairs or Remodel 0 Other <br />Comments <br />Packk ei hivtod ?frtsfreic 7C1 Ilif fir044/ h&c/a/A.4,7,1e "iz- <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />4V f 1 .02-Li 0 <br />VIN <br />ktAltil I e 5tb g-S VI 30W4- <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact ti Property Owner 0 Contractor 0 Architect <br />CI Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name..., <br />16 VI A- t-.1 Pc 1,0c4 <br />Address <br />Last name If contractor, indicate type and license number <br />2 5ce, 1+A- '1. FoRD 13' 0- <br />City State( jer zipci <br />Phone <br />9)A U2 S 1,51 b Phone Email 106 pa /21 __Fel sti,c rytrA j 1 . c o 7 vr) <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />FAst ls.laine th NI \,..1 Last name " e If contractor, indicate type and license number <br />Address <br />'"/ 0 vicps--v -1- \o-1') DV--- <br />City <br />Loo ) <br />State <br />CA <br />ZIP <br />61 S 24-0 <br />Igt) <br /> 240 -3e1S <br />eb one Email <br />CA_ ij <br />CI 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 <br />7---' • <br />Assigned To '—"----. <br />CI lc( E7 <br />Linked FA ID <br />PE / 6 3( bate Record Fee Number <br />Cch 4 ho <br />2....3 9..... <br />-p,A 237 — C'sx. 41 Z-319'374- Fn2-Pct 611/43 V 2+ —I 2-/3 (12-4 <br />A? 2-tiOotig%