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BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge th4gRitl aqd/204ject <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my wejokwytiiitmagNs <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQHMINAMModes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / BUSINESS OWNER 0 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: <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Sierra Snow SKIT:wed tee <br />Site Address <br />1-1-(05 Mon'ce Oio-toto Rye <br />City <br />Stuck-i-on <br />State <br />C.S4 <br />ZIP <br />APN Supervisor District <br />Type of Service <br />Requested <br />AdApplication for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />CC4 er \ if‘..9 per IrvNIr‘ <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />'Contact Types XI Billing Party ..Facility Owner 0 Facility Contact Li Property Owner 0 Contractor 0 Architect <br />required <br />.Billing Party SC Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />Se ph <br />Last name <br />Se.imeo.rS <br />If contractor, indicate type and license number <br />Address <br />Lk 2-QJCA 5 e_c_fto In Pr/. <br />City State ZIP <br />Phone Phone Email swea ene rail pur-l-nersici; pec3rncul.com <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 <br />PAYMENT <br />ZIP <br />Phone Phone Email RECEIVED <br />Accepted By <br />Se-A4' C . <br />Assigned To <br />\P cic.,k P. <br />Linked FA ID <br />bate <br />0(0110i2`k <br />P Er ,, f, 00,, <br />lA0 V i <br />Pee SIG2 .eth <br />Record Number <br />viL .iwg2 Es7 6,f) -213I- PR