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ER 0 OTHER AUTHORIZED AGENT 0 PROPERTY / BUSINESS OWNE <br />BILLING ACKNOWLEDGEMENT: I, the ndersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH D PARTMENT 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 t is application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL I <br />APPLICANT'S SIGNATURE: DATE: ufs) 244 <br />If APPLICANT is not the BILLING ARTY, 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 />Q New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name ei hcin oLds_ <br />. Site Address <br />IL <br />k) . .._.,h <br />ox <br />ct oda, State <br />APN Supervisor District <br />Type of Service <br />Requested . <br />Application for <br />perating Permit <br />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 />/ <br />Contact Types <br />required <br />0 Billing Party 7I Facility Owner 0 Facility Contact Property Owner 0 Contractor 0 Architect <br />0 Billing Party I 0 Facility Owner <br />cor-vuold <br />0 Facility Contact roperty Owner 0 Contractor 0 Architect <br />F-56, <br />1ed _. <br />r-0) <br />La <br /> strj--arne—Of <br />If contractor, indicate type and license number <br />dd ss <br />Ao_ <br />Ci . Statece, n ziq <br />Phone <br />)._.06( 1 t 7.. ] ?)(4 <br />I Phone Email <br />I: Billing Party 0 Facility Owner 0 Facilit Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last me If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone mail <br />EI Billing Party 0 Facility Owner 0 Facility Contact 1:71 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 worai Assigned To <br />n CA -CW <br />Linked FA ID <br />Record NumbeAf.N 0 0531 Date( <br /> P 1 A 2i-i <br />PE <br />1L9D I <br />Fee <br />1)1q211 Ov0 3(eg