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%S3\-i <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />1-..• <br /> <br />Site Address <br />2‘1\ A frl)ivo2 AvL,s- • <br />City <br />S-raCKToN <br />State <br />CA <br />ZIP <br />9 Sao S. APN Supervisor District <br />Type of Service <br />Requested <br />X Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />Mew MF F (ice creckrY) <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />q FS ‘A S 1— <br />VIN <br />'Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact LI Property Owner 0 Contractor 0 Architect <br />74,Billing Party ill Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name A Last name If contractor, indicate type and license number <br />Address <br />M631- 'SoNsPil Fy c--- - <br />City <br />-TkPc-\/ <br />State cA ZIP <br />9 S31-4 <br />Phone <br />&o01-346.---c-x-3- <br />Phone Email <br />as ko ‘e, b 0:Ncx\ k•-r @ Lout tkp b • CAD "' \ <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 />— <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architiltkamk" WWI <br />.6" VOW <br />First Name Last name If contractor, indicate type and licelynkimber "ft <br />" 1/ 1 <br />Address City State ZIIVA <br />.,A <br />N <br />1 <br /> <br />. 731. <br />O <br />ll <br />lk <br />ht,4 <br />l <br />viN <br /> <br />COON <br />AfiTilfz)v. <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 applicat',P at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br /> <br />0 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 />jeR C . <br />Accepted By Linked Assigned To claw , 0, m . FA ID <br />bate <br /> (4) I t t2.111L1 <br />PE <br />t(I2CD-5 <br />Pee <br />- . <br />Record Number <br />I-HD 24104) 4-3 2-