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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> KW 9 N C ROCK N j -P\0L L <br /> Site Address It y�� ` c ��o- Clty�^ 1 <br /> n ( State C ZIP <br /> APN ^l Supervisor District <br /> T <br /> Type of Service Q Application for ❑Consultation KChange of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> if mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑8hling Party ❑Facility Owner �Facility Contact ❑Property Owner ❑ tractor ❑Architect <br /> required <br /> fA Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name I o Last name KAUy If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> -rc;dq n <br /> fl Billing Party ❑Facility Owner Facility Contact ❑property Owner ❑Contractor ❑Architect <br /> First Na Me Last e If contractor,Indicate type and license number <br /> scc"o\1 <br /> Address�� � City��&YN Sit 7 ��1 <br /> Phone Phone Email cj CC�� <br /> ` 1 2�,g 3G1-6�1 <br /> ❑Billing Party ❑Facility Owner 11P Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name �aj tname if contractor,indicate type and license number <br /> 1 1 <br /> Address �O O Cov�rno��+f� �gr4- City <br /> —,�ZkbC1tbV-N State U <br /> Phone Phone Email <br /> 2-43q-642-985 <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 /> farm. n <br /> I also certify that I have prepared this app at' n and tha h or to a performed will be done in accordance wAh all SAN 1OAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'$SIGNATURE: DATE: V3 20 ZQ <br /> Q PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT "•�h �Nr <br /> Title V <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required A��j' <br /> AUTHORIZATION TO RELEASE INFORMATION,When applicable,I,the owner or operator of the property located at the above site address,Yf b/i h a the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY Et {]Cd1YlENTAL�jjEA 4 <br /> DEPARTMENT as soon as It is available and at the same time it is provided to me or my representative. E ' �Q <br /> Acce ted By Assigned To Unked FA ID �p T,q� <br /> 'e F G i V- - THE <br /> Date PE Fee Record Number <br /> Payment <br /> ElCash ❑Check li Confirmation ft (�[ Il (/1 <br /> 111 "'C 4 tX. Received By <br /> Rev 07/10/2024 <br /> �V ✓V�� <br />