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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 specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared Ch a lication and tha 4he work,to be performed will be done in accordance with all SAN JOAQUIN COUNpAii;ance Codes, Standards, STATE and FEDERAL 6w APPLICANT'S SIGNATURE: 0 OPERATOR / ANAGER 0 OTHER AUTHORIZED AGENT Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required SAN AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site ad dr release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY E DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. 0 PROPERTY / BUSINESS OW 1 DATE: I °WENT enteto N 0 6 2024 . I, Ntit • : • tithe EPA Tr Kiz=u)D-737 San Joaquin County Environmental Health Department Fie_ 2-t a 2-3 Application Form Facility Name , ck \ v Xa.V\ (' 01/A \ PD CI`VIci — i \ Site Addros A c 1\ Supervisor District U kl City '1/4,7SACUA )0\ '` State s ZIP 9fc S 6 L(fY APN Type of Service Requested 0 Application for Operating Permit 0 Consultation CI Change of Owner 0 Repairs or Remodel 0 Other Comments If mobile food truck or pumper truck License Plate Number VIN Contact Types required 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Na711 L..,—• Last\na im6 G_, \k.,( If contractor, indicate type and license number Ackil5ss 2 ....) ,...) .4 \-YrOAk `.',-1,\ .\v.‘,.(...Awt) State ZIF9 s-)„.-N q Phone )1.•sk)p k-k(55( Phone Email 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number _ Address City State ZIP Phone Phone Email 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP _ Phone Phone Email , Accepted By() _ Assigned To Linked FA ID Date PE ; ....._ i (06b Fee L cl 2 -cro ,, - IP --- Uld. Record Number (-+P 2 40046 -- fu22,--pc{ ca4ct : 152(0352/95--(e/a2