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<br />D New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form )12_0 zcis <br />Facility Name 4 <br />' 1,Glic-J2----lird '12L_ <br />Site Address 2 ..._ti go c--14200 7 u 0 c p_ 6 City .,_ <br />1-1311C q <br />State <br /> an <br />ZIPS <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation ,Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />gi Billing Party 0 Facility Owner In Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last <br />/C_V-16tie- iq <br />name H <br />City <br />If contractor, indicate type and license number <br />Address <br />Or-4)6/W, /39 q GM P(12-i&S LA-1 <br />— State <br />M - <br />ZIP <br />4111UCV-- <br />Phone <br />S_I',0----(0 <br />Phone Email . <br />dhlaCalejL16 -C-bY" <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 />El 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 />PA Yhq4=- <br />Address City State ZIP e.b r... ..... <br />" C CEI V <br />Phone Phone Email <br />43C r 0 3 20 <br />SAN j <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / BUSINESS <br />If APPLICANT is not the BILLING <br />AUTHORIZATION TO RELEASE <br />release of any and all results, <br />DEPARTMENT as soon as it <br />#0,,.. <br /> <br />I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all sitizmo 63•963 <br />-J <br /> <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business FlsIgAvi rir/NT <br /> <br />' DE-PA/iTAPLa. <br />this applica on and that the worto 1:Performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Co <br />laws. - . <br />Ilt <br />deV- <br />ACJI"--s <br />/ ,414: - DATE: 4 10/ 3/a9 <br />OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />PARTY, proof of authorization to sign is required <br />INFORMATION: When applicable, I, the owner or operator of the property located <br />geotechnical data and/or environmental/site assessment information to the SAN <br />is available and at the same time it is provided to me or my representative. <br />Title <br />at the above site address, hereby authorize the <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />Accepted By <br />'ae. C-• ' <br />Assigned To , <br />\<ckcke cmn-e, k-- <br />Linked FA ID <br /> r <br />Date <br />MCD.3 \ 2-44 <br />PE <br />(40 /3) /2- <br />Fee <br />TI -12- • 0CD . <br />Record Number <br />SR2_LI 00)543 <br />172.be) Ck_ 11-7 <br />TV <br />Rev 06/12/2024