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Linked FA ID <br />/ .1-F—S— 1 9 <br />Record:5n buq40/72 <br />Accepted By <br />v•-sr c.e—o <br />Date a <br />Poi 4 /62.00 eeet-f. -4/* /82366 3F— <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 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 laws. <br />APPLICANT'S SIGNATURE: EtNIZIAJ 140rr141-g-to-pv DATE: 6/12/2024 <br />X PROPERTY / BUSINESS OWNER <br /> 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT <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 />'S 7 1 2_5,71,7/15r <br />San Joaquin County Environmental Health Department <br />JUN/4 2024 Application Form <br />SAN <br />JOA <br />AeIVIR QUIN C A L. TH ONIKE„,OUN TI, <br />°SPA oh' v 7.4 A TMEN <br />Facility Name: Papa Murphy's <br />Site Address: 1894 W. 11TH St. City: Tracy State: CA ZIP: 95376 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />x Change of Owner 0 Repairs or Remodel 0 Other <br />comments: LonsairaTtein, Inspection & Change of Ownership q4ct-s..-i- vcc.pc, sA.kmAe p <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />rilling Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />X Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name: Emily Last name: Harrington If contractor, indicate type and license number <br />Address: 846 Sunnyside Lane City: Tracy State: CA ZIP: 95377 <br />Phone: 925-525-8464 Phone: 925-525-8464 Email: <br />Emily.harrington12@gmail.com <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 />CI 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