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0 New Facility <br /> XExisting Facility <br />Joaquin County Environmental Health Department <br />Application Form <br />FaciliV Name 1 <br />0....:c.oc i E r ,-\„, <br /> <br />Site Address ll g <br /> <br />i i'';'. 7 IQ ioc.c.: t2.. 5 Pr- A...:aiviiv--t-C' Rcl <br />City : 2 <br />4-0-0eci 19 ." vci, e <br />S3ate _ <br />Lt <br />ZIP <br />APN <br />C). i5 44 Se 0 k <br />Supervisor District <br />Type of Service <br />Requested <br />XApplication for . <br />Operating Permit <br />KConsultation 0 Change of Owner 0 Repairs or Remodel <br />ir <br />0 Other <br />Comments <br />VIN cn ppy If mobile food truck or <br />pumper truck <br />License Plate Number <br />Contact Types <br />required <br />0 Billing Party At-Facility Owner 0 Facility Contact 0 Property Owner 0 ,Contractor <br />.... <br />0 Architect <br />0 Billing Party A,Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Fir$ Name Last name If contractor, indicate type and license number <br />Address <br />oCi (6, g (-06c,(A. <br />„ <br />A pielq_e. A a <br />City <br />CO oecti3 r Ae. <br />State <br />CA <br />ZJP <br />Phone <br />2C: i - .3-7 3 7 g7 <br />Phone 1 Email r-Z <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 <br />RE <br />and license number <br />cgIVED Address City State <br />Phone Phone Email <br />2 7 2024 <br /> <br />NOV <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Co nOtYri RON MifliffAilect <br />DEPA <br />. <br />La IlEALTil RTM <br />First Name Last name If contractor, indicate type and liceP4 <br />fi'C <br />N7 <br />rAddress <br />yr PhC 0 <br />City State ZIP i VEC <br />DEC Email <br />7 !7 20 <br />1 I 2024 <br />84 N JO <br />BIWNG ACKNOWLEDGEMENT: I, the undersigned property <br />sOCific ENVIRONMENTAL HEALTH DEPARTMENT hourly <br />form. <br />I also certify that Lhave prepared this application and that <br />Standards, STATE and FEDERAL ws. k , <br />APPLICANT'S SIGNATURE: L iz oidgt 12,__,,,.......t u <br />L <br />or business owner, operator or authorized agent of same, acknowledgethatVlite irrtitiNtrA , v ry <br />charges associated with this project or activity will be billed to me or my business as identi ice4&41tItilt <br />/WENT <br />the work to be rmed will bed e in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> <br />-' r ,., _,..,..,- ,., DATE: i 1 PAYmeNT <br />_ <br />y <br />NROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT RECEIVED 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, htrifegYauagLi024 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRGINEW;SL HEALTH ' <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.IN ativili CouN <br />Maikt r,....4fEkTAL <br />Accepted By <br />Fr ck.ncAscc i2.- <br />Assigned To <br />riC,OCi sco 12- • <br />Linked FA ID &or...pARTm <br />sir FAMD3icit4 <br />Date PE <br />t (CCP 2-- <br />Fee, Record Number <br />0 Cash /Check # / 06-7 0 Confirmation # <br />Payment <br />Received By <br />Rev 07/10/2024 <br />btteD1340 C