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San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />600 c,_ J a iN s <br />Site Address 1 <br />P 1 (a 0 I 5 a i ki {IV gd Ci <br />( <br />ty ta , , <br />CV <br />State <br />4 <br />ZIP <br />( 95-33o <br />APN Supervisor District <br />Type of Service <br />Requested <br />ID Application for <br />Operating Permit <br />0 Consultation yitChange of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />II V u q 8 A. 2- <br />VIN L7//41 X C 2 3 3 2- <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact O Property Owner 0 Contractor 0 Architect <br />141 Billing Party iii Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name /. <br />S aryl <br />Last nameitlA j eauujejk If contractor, indicate type and license number <br />Address KGC (-Le 00 C _ Sk,-r u rac .. <br />City <br />L0.4.- <br />State c 0_ ZIP eic2q o <br />Phone <br />.02-4)Ci <br />Phone <br />.1A-4 7 2( ° -3- <br />Email., iffy 14 he u34. di sf•roe ivy\ c.,, \ • C it) 41 <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 />ZIP PAYilf <br />ftekfti: <br />e bfr11, I . <br />Address City State <br />Phone Phone Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 44 0 Arc <br />A00V A / /1844 p zi , <br />First Name Last name If contractor, indicate type and licenser -;(v 4 <br />E <br />Address City State ZIP <br />Phone Phone Email <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 <br />form. <br />I also certify that I have prepared this application and that the rk to be performed wi I be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Alt DATE: g 14 <br />o PROPERTY / BUSINESS OWNER 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 />Accepted By :ye c f c . Assigned To — . yoatanne L. Linked FA ID <br />bate <br /> <br />PE <br />NOS <br />Fee, <br />VOil -013) <br />Record Number <br />S 2:2-4$2.0 i+\ <br />P <br />igis_1766--