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0 New Facility CZ/Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />, Facility Name /-.) <br />U.i( r ni on AM ee 1 ss <br />Site Address <br />i --7 17 k S Uniori S'. <br />,.., <br />-e. <br />City <br />f-oc_ K-to-rk <br />State <br />C/ <br />ZIP <br />q 5Q-0(9 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation erhange of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />1:t- 31 9 9 1.- .1 <br />VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />gBilling Party 'Facility Owner Ig"facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name V"'N If contractor, indicate type and license number <br />Address --)..._, ...I.. S) \ y\ e_. p-0•6 0 o \-c Dy <br />City <br />'/N'O. C. k \u\f' State <br />C R ZIP q 5 -2_\ 1_ <br />Phone i;s0:464-1eNci Phone Email ', cr.-, <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 Archit <br />rAY <br />First Name Last name If contractor, indicate type and li r Al, <br />/1/Ez <br />Address City State ZIP JAN 13 <br /> 2025 <br />4" JOAQI i „ <br />ONAi <br />.4 I v cf „, <br />Hge.,-411'Tr,A:fuN <br />rj <br /> <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 ROVMENT <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 />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL la s. , <br />APPLICANT'S SIGNATURE: \)- DATE: \ V\ 2. 7— N\ C t 1 -23 0 17") <br />0 PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <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 address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Accepted By . ,. <br />.-..) • b . <br />Assigned To . <br />i< 1-• <br />Linked FA ID <br /> FA0 <br />Date PE <br />I (06;1 <br />Fee <br />14 I -7 <br />LL.Record Number <br />sR250014 2- <br />0 Cash 0 Check # <br />L.}...14 <br />/Confirmation # lq4 366.5 Payment A <br />Received By (1/t <br />Rev 07/10/2024 <br /> <br />PRoci stosq--