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Vacility Owner VI t-acility Contact r <br /> <br />Ailing Party <br /> <br />Contact Types <br />required <br /> <br />.'roperty Owner El Con ractor <br />fl t2 <br />o Architect <br /> <br />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 RTMENT 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 <br />Standards, STATE and FEDERAL la <br />APPLICANT'S SIGNATURE: <br />4rirPER1Y / BUSINESS OWNER <br /> fil*EFFOR / 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 />and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />DATE: k7Ikkk2z,k- <br />San Joaquin County Environmental Health Department <br />Application Form <br />Faclity Nas 6 Loy\ s eee, sait d otot <br />Sit Address <br />`,1 <br />i (40 k 4ZIP <br />Sp aciAolo DC aff'LA APN Supervisor District <br />Type of Service <br />Requested Weting Permit <br />plication for 0 Consultation 0 Change 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 />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Fi Namlkii Las\l-nalis 4) If contractor, indicate type and license number <br />A 4 s 3 4s,AAAD vc. C <br />v---k" <br />Stateck 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 />PAVIA P Al ir <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor ErWiett I VED <br />aruiliiNse1-lrib2024 <br />COUNTY <br />ENVIRONMENTAL <br />HEALTI <br />First Name Last name If contractor, indicate type <br />State EALI)i)JOAQUIN Address City <br />Phone Phone Email I DEPAR 1 MENT <br />Accepted By <br />1 `1 1Z1 YVVti <br />Assigned To -tRti,‘A.A.4.j Linked FA ID <br />Date <br />6 le PE 1403 Fee ly.. a 4 / Record Number <br />A Pg—q 0 0 q8L-1 <br />Veti V /A 6, <br />vrtiootoi