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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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />DATE: 1 2,. CO 20 eZ- RA YilleNr <br />Wenteb <br />Title <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required APR 2 2 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site ejedkr hereby a utIT44 the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENV• PP! PUIAt elfaC,Iti <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. hEALT °NalleliTuPi TY - 14 pep Ai. <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY! BUSINESS OW 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br /> <br />Facili ..2 ' . (3 1AT. . i I---Pfe A a 4a.-a-) 1/'.7--- ty <br /> <br />-----'_ _.. ----.>" ... v ts.gqt 14,1c1 (_.\ liv,A 7 _ Igg Qc, SI ZIP <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Commentscce <br /> <br />If mobile food truck or <br />pumper truck <br />License Plate Numb r VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name ,1.-1 ' Last name Sow ,E.2 If contractor, indicate type and license number <br />Add ress — _ <br />N 2-kr 3 -CW ("34)W3 C---T <br />Cit (.50 0 tevi\ State <br />CA <br />ZIP c-i-311_0 <br />Ct3in )2.2i(3tone itiA53/1 idu „) <740066ecyw:tifeczy.ti <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 -1 Assigned To Linked FA ID <br />Date <br />)4 1,3' <br />PE i - <br />kCI 011 <br />Fee ..1 2.....„ <br />-441 -5--Q .----- <br />Record Number <br />AP250/ 9 4/471 <br />0 Cash CI Check # 0 Confirmation # 2DO-15--r-)__:-+e <br />Payment <br />Received By 4 <br />r- <br />Rev 07/10/2024 <br />WZI-COL131-•