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1:1 New Facility l Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />U LA VA C I-I A all TIET---Jkis Ey•PR6ss Lii)f-To 0-6 P <br />Site Address <br />i4111/1---.4 ro (ID <br />City <br />(10A 1-A-Miz)e <br />State <br />(sec C- ,-.A- , <br />ZIP <br />cg.330 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation ,SChange of Owner 0 Repairs or Remodel O Other <br />Comments <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 />Jatilling Party ,Facility Owner 15,Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />.(.41 'VP 140A1l JAt.09"Stii(04.' <br />Last name <br />71-A Nfr, 0 CIA RI <br />If contractor, indicate type and license number <br />Address <br />4 0 <br />City <br />rA-T411-0P <br />State <br />c A i <br />ZIP <br />1 C310 <br />Phone <br />no -774-Pea <br />Phone <br />r <br />Email <br />cf,zA-7_yalA .1- r,-).--v (t)ektici(• ori . <br />0 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 />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name PA ifelif If contractor, indicate typg2 1 Elliot <br />Meeei z-rt <br />Address <br />, <br />City State <br />AAAR <br />ZIP 1.; la <br />2 5 <br />Phone Phone Email <br />p,d9 <br />4 <br />QuiN <br />2025 <br />r". .. <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <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 />APPLIC ANT'S SIGNATURE: <br />- . <br />I, the undersigned property or business owner, operator or authorized agent of same, acknowledeeniMICIOAtrioject <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as 'dent' i ris <br />this application and that the work to be performed will be done in accordance with all SAN JO QUIN COUNTY Ordinance Codes, <br />laws.itt klA 6:q .-)c : c DATE: <br />OWNER 11:141PERATOR / 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 />Title <br />at the above site address, hereby authorize the <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />Accepted By, <br />JeCc) (._ , <br />Assigned To <br />KcAck,cknn-e c_ , <br />Linked FA ID <br />FAVD 2.4ci(1),4 <br />Date <br />W'N 2-51 2-5 <br />PE <br />r loCO 2_ <br />Fee <br />3 VI- Z. ea <br />fl Reco4d <br />,c \ 1 ' <br />Number <br />3V.25-1)V1 dc co <br />0 Cash 0 Check 14 ,RConfirmation tt OV.123-7 q il <br />Payment Ck, <br />Received By <br />Rev 07/10/2024