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AP# <br /> San Joaquin County Environmental Health Department <br /> Operating Permit Form <br /> Facility me <br /> Site Address Ci LL State { ZIP C-� <br /> Bus iPgss�h`o{�e� 7-, S SSN or Tax ID# r- <br /> IF cilliity�Mailing Address City State IP <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck N IA Z <br /> Facility Owner <br /> First Name Last c" n me <br /> r G I ( Y-< 'c- <br /> Home Address City State ZIP <br /> L�1`1SZ ,aY,;, 'tY) --S "�3` U <br /> Mailing Address City State ZIP <br /> ► ems► At.. IQ` l�i),) `�-a l 6--� <br /> Phone Phone Email <br /> Billing Party <br /> First Name Last name <br /> Billing Address City State 21P <br /> 1 LAS� ��.r G�� v` ' ' v X c�S CLLI <br /> Pho a Phone Email <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this <br /> Business,and I acknowledge that all PERMfT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will <br /> be billed to me at the address identified above as the BILLING ADDRESS for this site. I also certify that all information provided on this application <br /> is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes <br /> and/or Standards and STATE and/or FEDERAL Laws and Regulations. <br /> Applicant Name /J I Signature <br /> Title Date Drivers cense# <br /> IP otocopyRequired) <br /> EHD Use Only <br /> Assigned To Linked FA ID Record Number <br /> Date PE Fee <br /> Invoice# <br /> Permit Valid from to <br /> Amount Paid Payment Received By <br /> ❑Cash <br /> ❑Check# <br /> ❑Confirmation# <br /> Rev 06/12/2024 <br />