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L7 Billing Party 0 Facility Owner 1:1 Facility Contact 0 Property Owner 0 Contractor Li Architect <br />First Name <br />Address <br />C2,0co <br />I Phone Phone <br />(5—) 703 f3c(r1eifl <br />Last name <br />(C)//a,7/e" 5 <br />Email <br />1776c3;I1-cl`10/ 9 (21 <br />If contractor, indicate type and license number <br />State ZIP <br />r, Cl -15 -7C,LY <br />City <br />Billing Party 0 Facility Owner 0 Facility Contact O Property Owner <br />First Name Last name <br />Address City <br />Phone Phone Email <br />CI Contractor 0 Architect <br />If contractor, indicate type and license number <br />State ZIP <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 OrAnance Codes, <br />DATE: / <br />0 PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br /> <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 addrest. <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY EN <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: • c <br />4)31 <br /> OR 2 4 <br />I .,. .4 , iithor,04 <br />4447)- ." 4 <br />0 New Facility t Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form ()82_25o0\-fib <br />Facility Name <br />/ Cr ((r2 de/ Vovic.c) <br />Site Address <br />/ :Y1 / c" <br />City <br />/CX <br />State <br />A <br />ZIP <br />9`75 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation )„change of Owner El Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />ilc)R /-1 Z 3 <br />VIN <br />—1-(7 (2) f2 3 2 fro .7----7 -7ce31 <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 CI 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 <br />--f- <br />Assigned To I, , , 1 <br />Is, • L ,..- INDortS <br />Linked FA ID -- ' <br />..„ , <br />Date • 1 , PE Fee , <br />n <br />Record Numberaluarixiga. <br /> p\p2,01q544 <br />0 Cash CI Check # ii Confirmation # 200QYZ51_02 <br />Payment <br />Received By 0072r <br />Rev 07/10/2024