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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 t catign and that the work to performed will be done in accordance with II SAN JpAO.UIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL la <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: to'oe, <br />al New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />c \-kolo ti c, frk,tcd4 u t'5 _ <br />Site Address . <br />111 1713 LI t tkrk(C b4 C5lit 20 <br />City <br />LO CI( <br />State <br />e,-ik <br />ZIP <br />q -C . q 0 <br />APN Supervisor District <br />Type of Service <br />Requested <br />);Application for <br />Operating 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 />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Rgilling Party ,thacility Owner ?facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />1740‘ Up <br />Last name <br />QVIA I 1/C <br />If contractor, indicate type and license number <br />Address te)42_ L) 11 2_ -) City <br />C13 D r <br />State <br />e Ac <br />ZIP <br />qc5 —#247 1(3 <br />LPhon) <br />90q 5rfl— qn0 <br />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 />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 />Accepted Bys \ <br />Je ic- C - <br />Assigned To <br />1-tanci;wc, (2- • <br />Linked FA ID <br />Date , <br />to 12t ZtVi <br />PE — - FQe. , <br />II e. c c <br />R4ord,hhimber <br />fit-'i 1e1211 <br />Rev 06/12/2024 <br />1=QT-10-6