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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 this 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 laws. <br />APPLICANT'S SIGNATURE: <br />)gl-laROPERTY / BUSINESS OWNER <br /> 0 OPERATOR/MANAGER <br />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 />DATE: 5/3 122-Y <br />San Joaquin County Environmental Health Department <br />Application Form P 2. <br />Facility Name <br />C-0),..-k-VeleAc <br />Site Address <br />111.1 . Uk.tiONSi ---c . <br />City State ZIP <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 ,_ <br />2-1009-Vi- <br />VIN <br />1 -F. PX e-I-Jr s-sg -IPA <br />Contact Types Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact b Property Owner 0 Contractor 0 Architect <br />121,Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />.\4-01,-6Pc <br />Last name <br />CoO.si-1 0 <br />If contractor, indicate type and license number <br />Address <br />4-11c 4. \I-01 /41-rutgA ---r. <br />City 1-"DjAir(6) <br />i-Voose- <br />State <br />CA <br />ZIP <br />c15.5c1 I <br />Phone _, <br />310.4Mq 44,29 <br />Phone <br />ClOcti--5041-05-Z-5 <br />EmakAo,y4 cos,eio <br />4,2-qe,i41-kCO.C-Chot <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 <br />....„....."4-trILI i____•,.,, <br />"RECEIVED <br />First Name Last name If contractor, indicate type and license number <br />mAY 3 1 2024 <br />Address City State ZIP <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT Phone Phone Email <br />Accepted By <br />\A <br />Assigned To Lv\ct ck Linked FA ID <br />bate s 1403 Pee Ik.02, '00 Record Number 1=0. <br />J <br />n p.5.qcol0 (0'4 <br />V a 12-- 41-7' 41z 2-2-1-01z--- 5-(u/kv21