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❑ New Facility fi� Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form 2to00 3 <br /> FanU[y Name <br /> {'U!N 74 S i J�/v C <br /> Site Address City State ZIP <br /> +fs,,�� ��771 S,~ -XI1C- Grp 753�d <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation 0 Change of Owner CKRepairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types. 0 Billing Party ❑Facility Owner ❑Facility Contact 19 Property owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑FacilityContact ❑Property Owner ❑Contractor ❑Architect <br /> First Name L Last name If contractor,indicate type and license number <br /> 5�7 ipi� <br /> Address r 1/-t-7' -5T— City State <br /> Phone 7 C Pho/ne'I Emlail C <br /> ,t'9-WY-//4 5R�'R �� <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name tf contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone one Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 0 Architdct� <br /> First Name Last name If contractor,indicate type and Iicen �]t�t IVl" <br /> C�`E� FD <br /> Address City State ZIP DELC <br /> Phone Phone Email SAN Jfl [y <br /> �QU <br /> 1 r, NrY <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all s to ans; <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 NT <br /> form. <br /> I also certify that I have prepared this application and tha the work to be performed w i be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. 7� `2/7- LI IZ '1 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT t'J I�NL <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 address,hereby authorize the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepw gy Assigned To Unked FA ID <br /> Ln <br /> d O <br /> Record Number <br /> Dates . PE b01 Fee �1R24 <br /> o ^ayment <br /> 0 Carob ❑[hecktl Confirmation p � `l 3 L� !')J�U�2 acelved By <br /> Rev 07/10/2024 <br /> D <br />