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i-- _ <br />If mob I :le food truck or ikons* Plate Number <br />pumper truck <br /> <br />1 VIN <br /> <br />0 Facility COntlet 't 0 Property Owner <br /> <br />Centact Types 0 Billing Party <br />required <br />0 Facility Owner <br /> <br />0 Contractor Archeert <br /> <br />Facility Name <br />0 Repairs or Remodel 0 Other 0 Consultation <br />-nroca ci5 37 (7. <br />San Joaquin County Environmental Health Department <br />Application Form <br />inabi bochls c- DeA i-h in <br />city r <br />Stale ZIP <br />) k:14-ch'n Zrokcna__6,usi re_ <br />ni drressi.s rya( <br />lie<ege of Owner 0 Application for <br />OperatIng Permit <br />Type ig Service <br />Requested <br />Comment< <br />APN upervisor District <br />DA' <br />0 Cash <br />Rev 07/10/7024 <br />ate <br />0 New Facility CiKsting Facaity <br />fibIlling Party iirri—cility4Di.vrier —0 facy Contact <br /> n Plopertv owner 0 Contractor 1 0 AnNtect <br />if <br />30 1 6, da-rolcielYms en* dtal- if Or cA 4s..3.30 <br />Address City Stale <br />Phone ' Phone Entail <br />3 7Th 73C1 ab Y rk;r,oa,i1c Pyra row) <br />U Contractor I 0 Architect <br />First Name Last name <br />First Name 5111(4-n1 <br />Last nine <br />ArrIVi <br />contractor, ledlcate type and license number <br />0 Billing Party LI Facility Owner Cl faciety Contact 0 Proixety Owner <br />:44 If contractor, indicate type and license number <br />Ernest Phone <br />Address, <br />Phone <br />State ZIP <br />uting Party n facility Owner 0 facility Contact El Property Owner iktiymEAl. r 0 Contractor 0 Arthit <br />If coreraLtue, indicate type'Tiii-JR °e/vEt) <br />State I ZIP S tp 2 7 <br /> OAN Jo '2O2 <br />1_ E)tv , ,, A QuiA , <br />11(41. i-4134),AimIZZuiv <br />k'cP4 0.,1 <br />BILLING ACKNOWLEDGEMENT: I, the undersigred property or business owner, operator or authorized agent of same, acknowiedgc that all site and/or pro <br />t, <br />letf r <br />specific ENVIRONOAFN T AI HEALTH DEPARTMENT hourly charges associated anthills< priNeCt or activity AO be Wiled to me or my business as identified on this <br />fern, <br />I also certify that I have prepared this a <br />Standards, ;TATE ancl f EDERAL laws <br />APPLICANTS SIGNATURE: <br /> <br />n aid at the work to be performed will be done irt accordance with all SANIOAQIN COUNTY Ordinance Codes <br /> DATE: 5119 4- I/A . ..2a2.11 <br /> <br />1/2(PO4ER.Tv / BUSINESS OWNER o OPERATOR / MANAGER 0 OTHER AU I HORIZEO *Glair <br /> <br />Title <br />If APPLiCANT is not the BILLING PAR) Y, proof of author la t1041 to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable. I, the owner or operator <if the property located at the above site address, hereby authonie the <br />release of any and all results, geotechnical data and/Of entre cairrienuti/site assessment information to the SAN PAQUIN COUNTY ENVIRONMENTAL HEAL' <br />L DEPARTMENT as soon as it is available arid at the same trme it et provided to me or my representative. <br />Accepted By Assigned To LineWATO <br />C—Nnnt:Ta(e_ L\r-Or\ove.5 r---6 000309 k, <br />\ken o -2_2— R4mgr14 1 <br />First Name Last name <br />Address <br />Phone Email Phone ma <br />City <br />PE Fee <br />OW* * "4onfirmation I kiS•Z)55 '402.