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New Facility g' Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form F (2 o IS <br />Facility Name/ <br />(0 <br />_ <br />Site Address ,c it Stateca Zip <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation <br />, , <br />0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments cv\ cacj t oc 0 totr <br />\ ,. <br />46 p <br />., <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 />gs Billing Party fa Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Firs/Name Last name • , / <br /> / <br />If contractor, indicate type and license number <br />Adpes.,-7 ,1 i ...1--- <br />62 ( ..--/ 6(4-(_ {-6.-iCy <br />State - ZIP ..,7 <br />tri--I f---) <br />Phone Email e--) ) 1 <br />A7 11101' CO t/c1hz.r6,44 <br />1:1 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 />O 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: <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 <br />HEALTH DEPARTMENT hourly <br />or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />charges associated with this project or activity will be billed to me or my business as identified on this <br />that the 'ork to be performed will be done in accordance with all S N JOAQUIN COUNTY Ordinance Codes, <br />/7 --.7 ,- Z-/ ,i DATE: t / <br />this ap.,,,tio .nd <br />laws. <br />..., . . d d r. V. . er <br />OWN • OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />, , / <br />RN, p oof of authorization to sign is required <br />INMFOR TION: 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 />il,.....PA <br />Title <br /> <br />Weir4 <br />at the above site address, hereby ntkoAthe <br />JOAQUIN COUNTY ENVIRONNSitieirsH_EALTFr° ak <br />., airt.:Qu - <br />Accepted By <br />Vidal P. <br />Assigned To , <br />a oecknoe 1-- , <br />Linked FAD ...Frio,„,;:mcivr,; • <br />fivin 1-3\AT} gPiurnigin <br />Date <br />1 t Z 5 0221-1 <br />PE . <br />C (C(V2- <br />Fee <br />$112. 0T ( -1-Q ' <br />Record Number <br />SR2400(005 <br />0 Cash 0 Check # Er It onfirmation I 91 2 9.--q--5 - Payment <br />Received By <br />Rev 07/10/2024