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El New Facility IA Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />1-41e 0 S c' 1 124 KZI>It Sll -4- id t-,--} 1 0,1 3 <br />Site Address \ 1 n <br />tit ni ovi S 1- - <br />City State el ziti ,2..,0\6, <br />APN Supervisor District <br />Type of Service <br />Requested <br />Application for <br />operating Permit <br />*Consultation 0 Change of Owner 0 Repairs or Remodel 0 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 />.)Villing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor • 0 Architect <br />First Name A .Last <br />VI Ilk <br />namev 4 A ..c -JT\---, If contractor, indicate type and license number <br />Address <br />17‘ 1 al Irn <br />City <br />1/1 .) <br />State <br />eiN 9 c2.1)1 /4,_p <br />Phone <br />.20,i- U/61-;-7 Phone <br />t01 <br />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 />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: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />4PPLICANT'S SIGNATURE: <br />o 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 work to be perfor ed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />lp ( r i <br />th <br />ti / (.6(''i ybATE: 0 1 ' 0 `-- i -5 Pil y f.g <br />OWNER 0 OPERATOR / 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 />C <br />N.y, <br />1 ite Title if) <br />144j U iR , <br /> <br />at the above site addr84 ereby autivori?Opp <br /> <br />JOAQUIN COUNTY ENVIRO 0.ty,IEALTH --U <br />ki„I L. iftyv iN COu th kEivr Nr}' op - <br />Accepted By Assigned 14A..., Linked FA ID <br />pt Do2 S-Z.L1 a'4vr <br />Date PE <br />IUU3 <br />Fee <br />I -) 2 — ------. * 1 -q-0 I <br />Record Number <br />s a 25 szo 1100 <br />13(Cashl in ...., , Check # 0 Confirmation # <br />Payment 1.1 <br />Received By I • • ' a <br />/ <br /> <br />Rev 07/10/2024