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Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />kr Billing Party WFacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />j my <br />Last name <br />To-r) <br />If contractor, indicate type and license number <br />Address m s_ i I <br />5m 14114/ <br />Cit <br />Am t <br />, <br />ny ed 0 te <br />State <br />CA <br />ZIP <br />95-3 s-r- <br />Phone <br />10 -, q/ i. - 7 ,IX <br />Phone Ereail <br />row kirde arwi , tor, <br />0 New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form k)1 1.0-ik'6i'S <br />Facility Name <br />D. <br /> 1,../ Vi elilLi 01 eS *e -c4nd C he 44.1"-() b0/4 *ecj . <br />Site Address <br />La 4 \re? p kv d 1.7.Ze-, <br />City <br />/444 v-.0 tro <br />State <br />C....4 <br />ZIP <br />'? C .3 3 d <br />APN Supervisor Dittrict <br />Znge Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation ' of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate umber <br />4/. i S C*E -r <br />V <br />--.5a A aCtin IC .5.-2 KO1 0 50-7 5 2- <br />0 Billing Party O 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 lil 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 />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or r4itiect <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifie VSA A, <br />form. Ii. twelfir <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 Ordina vet, <br />Standards, STATE and FEDERAL laws., <br />APPLICANT'S SIGNATURE: ,p,er 7 -Adi DATE: `7 / /' AIL 1 6 20, <br />47 <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <br /> EAn _AQuiA, _ <br />HeAL- vi..,..olvatitouNry <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required iri Ocf- PARIv TA , ra 24. <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize tlftffENT <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 <br />CCLY if 14 E S c_. (j <br />Assigned To <br />L:t el \ (1 CxX t.- S <br />Linked FA ID <br />FA ea2:74q5 <br />Date <br />i\\ so <br />PE t(.,(Dz Fee s v,12 .00 $1.,_ z_____, Ro riiirikeiv , <br />30 3 <br />i pai cAl ca/Lcf- c8P <br />1-60(2i-1-