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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 ap <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />\i PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER <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 addre <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIR <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />icati t the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />DATE: <br />1:1 OTHER AUTHORIZED AGENT <br /> bl3A <br />.1P" clvt <br />y 2 CP <br />hereby au 0-1/1z?091 <br />04L-IcHou's 7 <br />N 1/0 <br />r4cobbg2_4( <br />Dk2-`tc02-Aft) San Joaquin County Environmental Health Department <br />Application Form AP L 00(oz2. <br />Facility Name • <br />1-Cr ()TIC& r0,- <br />Site Addre ss 6 --to s s ac yck 0,e i to City4 ci , 2n) <br />ys --2-44 ,0 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 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 ION- -3 R6q <br />VIN <br />qmclulul—Dcorp_s O4131 6 Z <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />\1=1 Billing Party n Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />C a f t 05 <br />Last name <br />05Orno <br />If contractor, indicate type and license number <br />A <br /> ddres <br />23 <br />s liW ELIA C -I- <br />City , <br />0 <br />i <br />L. 6 <br />. <br />1 <br />State <br />C A <br />ZIP qszto_ <br />Phone <br />2°71-3521sq <br />Phone 2p qs 0-7 9 Email <br />12orio til 1020 1-1 0111A C61, OE S <br />0 Billing Party 0 Facility Owner 0 Facility Contact CI Property Owner 0 Contractor El 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 C O, IrrIA e.3 1.2-ti Assigned To -1:-._ Linked FA ID <br />- "wi ,itmaz <br />bate__ <br />S -- <br />i,--4 PE Fee <br />4N-a10.---- <br />Record Number 1 <br />0016#-:(Biy-f-n-510/2!-/-07171