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El New Facility X Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name -1-c xci, s _ou r\ --i- ..()\ -I- I nc k Site Address 1 7-1 I Up y0 se_ rn) Ave City NAon-tecc\ State — --- A ZIP -1. APN Supervisor District Type of Service Requested it Application for Operating Permit 0 Consultation )2:t Change of Owner 0 Repairs or Remodel 12 Other Comments If mobile food truck or pumper truck License Plate Number VIN Contact Types required 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect 0 Billing Party 0 Facility Owner 0 Facility Contact Pi Property Owner O Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email V:I Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name 1,-IcA0 , c l• 0 Last name c\--A Of ff , If contractor, indicate type and license number Address I ----) City State ZIP Phone 2:.J:i V") 0 l D3 9 71 Phone Email El Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email BILLING ACKNOWLEDGEMENT: specific ENVIRONMENTAL form. I also certify that I have prepared Standards, STATE and FEDERAL KAPPLICANT'S SIGNATURE: ig PROPERTY / BUSINESS If APPLICANT is not the BILLING AUTHORIZATION TO RELEASE release of any and all results, DEPARTMENT as o on as it I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this this applic.tion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, laws. __,•,-...—,_ 'ATE: / 21/ 6 -2Y OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT PARTY, proof of authorization to sign is required INFORMATION: When applicable, I, the owner or operator of the property located geotechnical data and/or environmental/site assessment information to the SAN is ailable and at the same time it is provided to me or my representative. PA Yitfr. Title li'c cN VAIN?' at the above site address, hereby authorize Mt- JOAQUIN COUNTY ENVIIIQNMElltAL YiE6IT I),,, "N JO we4 • Linked FA ID _____ Accep - i Assigned To Li --"Lrficr*Vi!uNry F 19 0 0 i 6050 P4p, .44 Date 12-11(.2124 E t • qcs 0 2_ Fee t —/ 1 Ati -4-a •, Record Number 'yr sg 2 q eo-i- 13 • 0 Cash 0 Check # 6/Confirmation # 9 3(1,29 pg Payment . Received By . Rev 07/10/2024