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0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />---Scion-)c) tiY\ a <br />Site Address <br />‘Q)--2-C YY\eaLarw) \-0-4- 1-r-N. <br />City <br />1 ra <br />Statg _ <br />_c)-__ 3-1 Lo <br />APN Supervisor District <br />Type of Service <br />Requested <br />Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />A <br />. , <br />/et:0 CEO class <br />If mobile 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 />s?(LBilling Party )(Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Name _... 0....a---- Fl Name e.i.r.:::....."_, <br />4 <br />ame L..astA , hou <br />(<...._ <br />If contractor, indicate type and license number <br />Address <br />d tcyao meatuo Lo-YV- \--r\- <br />......citsrac IA Staten ZIP <br />3 <br />Pipue <br />btl- 4471 -75T40 <br />Phone <br />CA 0 C. <br />Email <br />KOCk10-0 CD I CD e W -cLt' c At- <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 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 with this project or activity will be billed to me or my business as identified on this <br />form. <br />Standards, STATE and FED <br />I also certify that I have pre a d this a lication and e work to be performed will be done in accordance with all SAN JO QUIN COUNTY Ordinance Codes, <br />RAL <br />APPLICANT'S SIGNATURE: . 6L-Ks;---__. DATE: -76 Li PA 13f <br />Re ENr <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <br />ceiv,, <br />JUN 2 n 44) <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 addressaw authorire t2J24 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRON <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. • <br />In CCI:-ZA/V <br />Accepted By <br />7-Jeff C. <br />Assigned To , <br />V..acieck.nAki., C.... • <br />"giREivr ,iorgA els 12:2, g ---.., <br />Dat Date <br />2 Z ?-,- 1 PE <br />I kW e3 Fee t i (a, . (DT f !run ............ <br />( Mt I <br />Record Number Lliliec) 331 <br />/9P2-LtaZ531 ____----' <br />(b\vD 4A53(Qictid 4-c _21Erd <br />11U4 g 311-v