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San Joaquin County Environmental Health Department <br />Application Form ROst-l-133 <br />Facility Name <br />Site Address I <br />1 11"k <br />City / <br />0"'(Y/'t <br />Stateo A-2VO <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation ic Change of Owner 0 Repairs or Remodel 0 Other <br />Comments t\AFC- Cbc449-e oC OwnerstA.Ato <br />If mobile food truck or <br />pumper truck <br />license Plate Numbe <br /> <br />__ .,., <br />t61(76.3 2) <br />VIN <br />ra 3,29 3321/1 <br />tontact Types Of-Billing Party 714 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Nam/16(44a_ Last namC If contractor, indicate type and license number <br />Address - <br />-Ioa <br />State el ZIP "576 <br />Phone <br />,,9-4*- it,- 3/71.1 <br /> Phone Email eQ_, OtAec.94, r <br /> Ci tY7t <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 />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 />1 <br />BILLING ACKNOWLEDGEMENT: I, the undersi ned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPART NT 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 fLtion and that the work to be performed will be done in accordance with ll SAN JO QUIN COUNTY Ordipsf <br />APPLICANT'S SIGNAT E: DATE: 60 It Ricritqfr <br />0 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT <br />Title MA r ‘0 D <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required JOArt, ,. 24' <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addresitirtIttraw ;tie <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRO <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. EPAN r 7AL . r <br />itiENT <br />Accepted By <br />3-e- C C C- • <br />Assigned To <br />1-yancisco R. <br />Linked FA ID <br />Ft:VDTS-1-18G <br />Date PE <br />\ 6030 3 <br />Fee <br />S k lo 2 • DO ita <br />Record Number <br />c12-24(10)(1 <br />1%\cdt114 <br />Standards, STATE an FEDERAL laws. <br />pCPROPERTY / BUSINESS OWNER