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❑ New Facility L9'Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name )L Noodle <br /> Site Address City State Zip <br /> 8l lQ We Ln 103 $ S�ck�ran CA �15ar0 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation VChange of Owner Ll Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party El Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Rf Billing Party 9 Facility Owner Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> 'lo;zb Tennal1rtde S4-oGk�, CA R5alo <br /> Phone Phone Email <br /> L26 '�onPh 99q [� ah o.corn <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ` <br /> Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Biliing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <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 work to be performed will be done in accordance with all SAN JOAQUIN COUNTY�dfFisr���� <br /> Standards,STATE and FEDERAL laws. <br /> A DATE:APPLICANT'S SIGNATURE: 5 I' <br /> Se <br /> AP �inep <br /> hd PROPERTY/BUSINESS OWNER ❑OPERATOR MANAGER 0 OTHER AUTHORIZED AGENT JnA <br /> Title J <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required ��1 CaQuINC <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site add�HSYiG����A/d <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMEN <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. � <br /> Accepted By Assigned To r Linked FA ID t A�mm a 73 <br /> � <br /> Date ' R A PE w o Fee r Record Number25- S g a 4 <br /> l Payment <br /> cyc-ash / ❑Check q ❑Confirmation Jt Received y <br /> Rev 07/10/2024 <br />