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AP# <br /> San Joaquin County Environmental Health Department <br /> _ Operating Permit Form <br /> Facility Narne <br /> Site Address City e, State ZIP <br /> Busi ess Pone SSN or Tax IDff <br /> Facility Mailing Address City;— State ZIP <br /> If mobile food truck or License Plate Number if—\ <br /> VIN <br /> ck ipumper tru <br /> Facility Owner <br /> First Name Last name <br /> cy-� <br /> Home Address City— State ZIP <br /> `-'l Z_\ . �v� -� r f v<� ' � �,k- -cry_ c i C 1 S2 t S <br /> Mailing Address City State ZIP <br /> Pi <br /> Phone Phone Email r/ / I <br /> Billing Party <br /> First Name Last name <br /> :j <br /> CA. -,e t <br /> Billing Address City State ZIP <br /> Ph, ne 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 PERMIT 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 Signature <br /> Ce'i tiKcY f ' e'r ` -- <br /> _ r <br /> Title Date L� Driver's License 4�-2 _ r ` (Photocopy Required) <br /> r. <br /> EHD Use Only <br /> Assigned To Linked FA ID Record Number <br /> Date PE Fee I <br /> Invoice 4 <br /> Permit Valid from to <br /> Amount Paid Payment Received By <br /> ❑ Cash <br /> i <br /> ❑ Check 9 <br /> ❑ Confirmation f# i <br /> Rev 06/12/2024 <br />