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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 applicat n and t t the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Ws, <br /> DATE: /0/Z, /Z_V <br />Title ' '•° <br /> <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, ,•-ii,414, • the 4 A <br />, .„,,, • ,9 ,1 <br /> 417 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONME* 'I, i .Ylgi . ectifrus <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. 4*h_ <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY! BUSINESS OWNER OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />New Facility <br /> <br />0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name A _4 <br />T--- t_ex-71-0( r(\c/t <br />Site Address <br />S'S L.L.) k-1 a( d io c•\ .i.) cx 4 <br />City <br />s-voc_x...-iu,--N <br />State <br />CA <br />ZIP <br />APN Supervisor District <br />Type of Service 0 Application for <br />Requested Operating Permit <br />)(Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />previoair -ei perivu-/ed ;Pi Sam ni A C e bud, <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />\ii n t -71 1'1- <br />VIN <br />3'c-c1 I 11_ I 10-3- 9 OW ?_:3 I <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />y,Billing Party it-Facility Owner P.-Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name esli i <br />octe 0 <br />Last name,..—t <br />Vt., c.itel- <br />If contractor, indicate type and license number <br />Address : <br />Gpol S- wo, (-\e,, A .j -City <br />s-koc. -Hoc\ <br />State <br />c A <br />ZIP <br />Phone <br />-4,407 ul X11190 <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 />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 vi, ci cd i 0, <br />Date <br /> <br />Assigned To - ' ,, r , DI J-\-- ri At icc 47, <br />Linked FA ID '444 <br />we 0,----5 Fee i: \---\ /2_ 1 (.....4... i Record Number <br />PP2z / 01222. <br />Rev Rev 06/12/2024 12:(.1c( Fp2D02.51 <br />cc4-1110W),2601 (D15012q - -