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0 Billing Party .,,,Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name , <br />C/hrk SI 1 1\0=t- <br />Last name <br />1;_a.tsst4hs- <br />If contractor, indicate type and license number <br />Address City <br />11 2-•A <br />State ZIP <br />p46,,, <br />4 9 I 5fY130 <br />Phone Email <br />C729e.eri?(1,1)(6 ., <br />0 Billing Party 0 Facility Owner 0 Facili 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 :..ce. c. <br />Assigned To Vidc\I P. Linked FA ID 7/lDOD/3 IT <br />bate Do Ito t2.4 PE t tp 08 Fee st .,(.. 00 41a04 Record Numberc 5 q 6 ?p_if 003+ <br />6(.Q. paid. cibutd- cemp:IM3(9u3-03 — (Pt <br />San Joaquin County Environmental Health Department <br />Application Form ' <br />Facility Name <br /> <br />Site Acl(rpes I) 0 os.‘w .A4t, <br />ci'194C \•I <br />StM ZI1 16 3 <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 />New CCO <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />I Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />] <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 />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 on and that the w be performed will be done in accordance with al SAN J9AQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDE <br />APPLICANT'S SIGNATURE: <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&akirk- • authoriz 4e <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. HEALTH g ivmEnrrA, <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRO kovivouivry <br />4RT <br />PROPERTY / BUSINESS OWNE 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />DATE: 0 24:P PAYMENT <br />REC <br />EIVED <br />JUN 1