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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 app cation and tha he work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL I ws. <br />1 APPLICANT'S SIGNATURE: DATE il-r 7- 2 ,( <br /> <br />V6ROPERTY / BUSINESS OWNER <br /> o 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 />0 New Facility 'Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Nam <br />I "TO-Lac) kt -1-Okk) tr,7-0 <br />Site Address <br />1717 , 0 ikc;_ov -k- , <br />Cityi <br />5-1--nrA2zAcc4 <br />State A <br />C./ ....,. <br />zi <br />P 95266 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />S F 4a ci 1 S'g <br />VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />'Billing Party tifF acility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br /> <br />Firs Name . <br /> <br />. A ciwAv‘cid: <br />a. a Ast nT m,e u 0 il. If contractor, indicate type and license number <br />Ad ress <br />4. <br />,ity <br />kti,V.--vvy. <br />State <br />CAA , <br />ZIP <br />c1S-10-+ <br />^Ahone _ <br />Ye (AI -38.74 - it <br />PhoW <br />-LA <br />Email <br />0 Billing Party 0 Facility Owner fFacility Contact 0 Property Owner 0 Contractor 0 Architect <br />„,24/Name <br />_riertrii() <br />Last name <br />C C Ad\ 44"- <br />If contractor, indicate type and license number <br />ss <br />Phone <br />Roe& ‘D-k()---Lot74 <br />C ILA k cY Preydri\A-c.-- Pho Email <br />City State (7_,A _ ZIP <br />c't Szc-n— <br />71. <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or projerANEA/7- , <br />Accepted By 3.c., Assigned To l<1... <br />Linked FA ID <br />VA 00 ail q -1. 1 <br />Date PE Fee _I <br />d <br />Record Numbe r 2. 02.3 <br />IA. <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 ArchitectpA , <br />im„tri ME <br />First Name Last name If contractor, indicate type and licensf ACieJr. <br />CA, <br />Address City State ZIP NOV 0 ? <br />R _ <br />Phone Phone Email JOAn ZN1/F? 'ON c <br />Hekrk, °NA.4g..°41 <br />Rev 06/12/2024 <br />.?R oSL13 cA