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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 />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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL I <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / BUSINESS OWNER <br />DATE: <br />XOPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <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 addre3Iir. authorize th:e: <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRQNef vt141.41Xj, <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.0A14,7k-uUNri, <br />1)-1' rAt <br />Title '41, <br />ifkewm <br />`IEtZlitEr <br />Accepted By I Assigned To 15 Linked FA ID <br /> <br />Date <br />— ,...—/ A PE Vni, Fee • Record Number <br />1. /-7P250/L/47 <br />Di <br />0 Check # 0 Confirmation # <br />Payment <br />Received By <br />1 <br />New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form /sco-3Doi <br />Facility Name i C v^-eti-7A-' 0 A i <br />.Site Address 1,3 0 <br />5- • COat POltifirt, 'k ' <br />City ,.11.... j State <br />CA <br />ZIP _ q 520 S <br />APN Supervisor District <br />Type of Service <br />Requested <br />)(Application for <br />Operating Permit <br />)(Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />CvtA i"--- <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />Li <br />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 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />—ace, FA Sato <br />Last namti ,.2 c t -.\ v a..p A iy If contractor, indicate type and license number <br />Address g ..et (40 <br />A-Y1(4Q Ck • City si,frx ,..3 State 0.A ZIP I 5-zt-0 <br />Phone <br />PA • i6\ • Liq0-2, <br />Phone Email <br />Rev 07/10/2024