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OISL 1-1 92_ <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name 13 <br />eeClk i rrt k1C) hist(' "I- t <br />Site Address Address <br />00-i' i .46, Di- City State ZIP <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation hange of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />.X1,3illing Party CZ_Eacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />rkt cl..4) k .j <br />Last name .--3 <br />/5 e-e_ele,," If contractor, indicate type and license number <br />- <br />Addrps., a_co City State ZIP ‘•te (c_, <br />/Phone1 _., 5ZI-2gre Phone Email <br />b eftcAl A Au 1 .r i'r t'ai,. <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 />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 hi c associated with this project or activity will be billed to me or my business as identified on <br />form. 1-1Yattk ,,, <br />I also certify that I have prepared this app r. ion d t the work to be performed will be done in accordance with II SAN AQUIN COUNTY Ordinanckerek, "...,1,7- <br />Standards, STATE and FEDERAL lawy <br />APPLICANT'S SIGNATURE: <br />6 /0 zr citezi, /0 DATE: JON i n <br />0 PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT SA <br />NJOAQ <br />' U <br />2024 <br />Title /.., EVLIii, UN <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />• ,P <br />—/I <br />A , <br />-rii o <br />OA, <br /> 41Z-At <br />Co/ , <br />-piv,rAu,Nr), <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authoriteRNUty-4.. <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH • ftr <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 />-3e F c . <br />Assigned To 1---k3c\'‘c. 1 Linked FA ID <br />FR 1102.00-9-s \ <br />Date PE Fee 4 to z iza) <br />U9 :---- <br />$(,_, <br />2. <br />_ Recor;digvnber <br />AK b(2.3444:1)2:33- <br />XLINLe2,— (z7 cat141, 8/2e -a2cf2, <br />- d(0(2q.ceffe