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Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATUR\ Alt (<7.0, DATEI:\ <br />/4fr-PROPERTY / BUSINESS OWNER <br />2024 <br />PAYA4 r <br />RECE <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 this applicationan that the work to be performed will be done in accordance wit all SAN Je • QUIN OUNTY Ordinance Codes, / <br />0 <br />0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT <br />Title IVED <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required OC <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorire Re9 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMEN15MEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. `1UAQUiN <br />_" Ailtiry <br />— <br />El New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name A .. <br />C co <br />Site Address_ 5 <br />---1 --- <br />City_ „ State ZIP 9s <br />APN Sup visor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />„arbilsultation 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 VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Billing Party „Iafacility Owner ,,2116-cility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />eA 1.-Ve...) <br />Last name of\ c <br />Ce—K Orc a S <br />If contractor, indicate type and license number <br />Address <br />t g 6 Cs2_pc\---or\ v.A City <br />-cc.i,J_of <br />State <br />cfaTe-- <br />ZIP ais 3 ,z_o <br />Phone ho 1zz_ ____ ..3 <41- t <br />95[ <br />r:ie 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 B( yli\t2_ ____.„ Ass' ned To . <br />r- <br />Linked FA ID <br />EPO(Plto62-5- <br />• -cHAR T <br />Date f 1 <br />(0 912.4 <br />PE <br />(903 <br />Fee <br />i 2_ -- Rssord Number <br />--i- 4 !S (Qt22 4-40Cf)558 <br />ENr <br />c6u/k_- KDH 21-! - <br />W052.11(01 6)1 <br />Rev 06/12/2024