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� 000zs�8S <br /> Rev ,ANT <br /> San Joaquin County Environmental Health Department 1VFp <br /> A p p I i c a t i o n Form AV.2 LL t j��'O"nl 2024 <br /> Facility Name , c I� RO N <br /> I / 1 J C UJ REALTH p�P FNTgL <br /> Site Address S SACP/ I MEN TD Sr City State Z� Oc1VT <br /> APN Supervisor District 1J <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit Comments <br /> ({/ /f <br /> J7 <br /> If mobile food truck or License Plate Numb r 1 /� (� T'�Mll <br /> VIN + rJQpumper truck V �X �.0 �f L G ?,a 3 <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Nam (� Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> 5b R/- - RD D V- L-0 D i C'on— s z q-C) <br /> Phone Phone Email <br /> U 2 Cf fi.t6 S C C^' ti l � c U►�Yl <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Fi st Na e_ Last name <br /> If contractor,indicate type and license number <br /> 1 � LC) <br /> Address �O� I) D � city��t) ' State ZIP"I c 2-4L) <br /> Phone one Email l� J <br /> m <br /> ElBilling 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 wit project or activity will be billed to me or my business as identified on this <br /> form. <br /> I also certify that I have prepare plicati and that the work to b orm will be done in accordance with all SA q JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. 6 <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/ZAGER ❑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 /> Accepted By 1( Assigned To �Jr <br /> S Linked FA ID <br /> Date PE 3 S Fee 3 Record Number <br />