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0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />L- — v\-\k,AN <br />Site Address <br />6 -.4...;‘-kc1 ? c.c.. k -c- .\ c... .,.i (,L___.. <br />City <br />c-, v,30\--2.. ,-... <br />State <br />C., <br />ZIP <br />c\c.1, -,',.:, "V" <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation Change of Owner <br />. <br />0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN L <br />Contact Types <br />required <br />(Billing Party 0 Facility Owner g Facility Contact 'Property Owner 0 Contractor 0 Architect <br />X1,1_3illing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />NI (\NI ‘44')C.\- <br />Last name <br />\\C't ) <br />If contractor, Indicate type and license number <br />Address <br />'..),. '2)..3 lc- '-4./\(,\c,\,,N ''-:,(.1.;.,' \ PNNiQ____ <br />City <br />\\z \.(:--\'\\ ;!%.._,L <br />State <br />Q._ N <br />ZIP <br />AS',S3 -\-- <br />Phone <br />ej U, c 1-cs'*-(' <br />Phone Email <br />0 Billing Party 0 Facility Owner ,5ZLEacility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />-)C2k\t' 0 <br />Last name If contractor, indicate type and license number <br />Address <br />6 3 Lie I Fc.c._ City , State ZIP <br />Phone , <br />i'11%),- 31- <br />Phone Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact <br />, <br />42.Zoperty Owner 0 Contractor 0 Architect <br />First Name ..0 k ‘ Last name If contractor, indicate type and license number <br />Address <br />73t-).3.)4•1 V <br />City State ZIP <br />Phone <br />- V6,1 ' /3/ (- <br />Phone Email <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / BUSINESS <br />If APPLICANT is not the BILLING <br />AUTHORIZATION TO RELEASE <br />release of any and all results, <br />DEPARTMENT as soon as it <br />I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />, this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanctl I, <br />ii t <br />i— <br />laws. A7.7...._ 2,_ <br />DATE: filf-. DATE: C% . Al al P \ <br />OWNER 2PERATOR / MANAGER / 0 OTHER AUTHORIZED AGENT <br />PARTY, proof of authorization to sign is required <br />INFORMATION: When applicable, I, the owner or operator of the property located <br />geotechnical data and/or environmental/site assessment information to the SAN <br />is available and at the same time it is provided to me or my representative. <br />AUG <br />Title <br />0 i <br />SA N Jo _ <br />at the above site address, fing124t <br />JOAQUIN COUNTY ENVIRONMelfti REA / <br />PA R 7.7 <br />Accepted By Vidal Pedraza Assigned To Lydia Baker Linked FA ID <br />.09 (DOCt) 239 (I), <br />Date 7-31-24 PE 1602 Fee 172 Record Number <br />SP-2_Li CO3 513 <br />Payment 185642839 17.2.6%) . IgS642-537 <br />P'0402 5 1 <br />Rev 06/12/2024