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1:1 Billing Party <br />0 Facility Owner <br />0 Facility Contact <br />Property Owner <br />0 Contractor <br />0 Architect <br />'Contact Types <br />required <br />BILLING ACKNOWLEDGEMENT: I, the undersigned p <br />specific ENVIRONMENTAL HEALTH DEPARTMEN <br />form. <br />I also certify that I have prepar <br />Standards, STATE an <br />APPLICANT'S SIGNA <br />fty orIusiness owner, operator or authorized agent of same, acknowledge that all site and/or project <br />ci s associated with this project or activity will be billed to me or my business as identified on this <br />e done in accordance with all SA OAQUI COUNTY Ordinance Codes, <br />DATE: <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER <br />Title <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required JUN 1 1 AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above gittod ress, hereb <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUkTY i LA4KAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ki9j. Ifil°Aii; CVATY Til <br />0 OTHER AUTHORIZED AGENT <br />rize the <br />San Joaquin County Environmental Health Department Pe.2-`*002-35- <br />Application Form <br />Vald , (g /,/9 q ri4 61Dso.--zgi <br />Far <br />ame <br />_re-0$1,0—rL Ci2-Akfe}1 <br />Site Arriss, seaA-cut City <br />APN Su ervisor District <br />Stater, A <br />L/7 <br />6.--7c-frerAlta, <br />ziP9,573.3e5 <br />Type of Service <br />Requested <br />Comments <br />JgApplication for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />A Billing Party q Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Lastpime .i._: If contractor, indicate type and license number <br />On i 1 k. v I C5 ----- <br />Address f), 0 , irte2yr ? City ),A j_kvp State 0A... <br />ZPS 330 <br />(e":9_ j \/ <br />,,, <br />,59 q-71-aosi hone Email <br />\If\ e.c,..r a e..-\--ro, k 2:2-e @ 0, V\ 1/43\ C—INCY-X <br />0 Billing Party El 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 By <br />IeFf C. Assigned 'co <br />K_cA_deCkAr\v\rC, <br />—64-xig-1. <br />Linked FA ID Eiyr <br />FA OOP 2:IlkLi <br />Date <br />VOkkk \ 2-4 <br />PE .1(oci -Ls <br />it <br />Fee <br />t tit 2 <br />,. <br />• Sited - 14 AP2 <br />Record Numblia 41_44 <br />(W.' pad Oa4 IN11411—(1) LQ(II 1 2-1 <br />e-2/