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0 New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form Penv2s-TS <br />Facility Name yjitvi4y S 145 H 1 <br />Site Address <br />/2't'/ A)," Aw v •c r , SarTE- /6 <br />City g . i., ci/ State <br />A <br />ZIP <br />APN Supervisor District t. <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation iift 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 />9i.Billing Party 0,Facility Owner '.,Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name -A.ekt5 Last name - (S" If contractor, indicate type and license number <br />Address 36d. pionto z,/t/ City -7 2 State ,. , <br />eLA <br />ZIP <br />Phone i .. Phone Email <br />ti kna-i-Vii.43 3 t 1 6Aisiat leoi... <br />0 Billing Party 0 Facility Owner 0 Facility Con/tact 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 />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 />APPLICANT'S SIGNATURE: <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 ap• ation and that the work to be performed will be done in accordance with all SAN JO QUIN COUNTY Ordinance Codes, <br />laws. <br />DATE: /0/2— / 142)--- 84 'Ur • 0"--."" I' <br />OWNER 0 OPERAT•R / 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 />yil , <br />,,'E•ce-.1"E. <br />Title till <br />at the above site address, hereby authorizeithep, <br />JOAQUIN COUNTY ENVIRONMENTAHEAL'TH kik' <br />EAZ:AQU/isi ;7,,vioN0/04 Cciov <br />Accepted By <br />14dS P <br />Assigned To <br />6 ,:qi F. <br />Linked FA ID r 6FP,j .1jV 7AL <br />FA ecinc041 <br />•,7-,4„... <br />Date <br />\ cA/, \\ PE ! (o (00 Z <br />Fee l, -occ, <br /> m,-- i Record Number <br />siZz4/00590 <br />Rev 06/12/2024 <br /> <br />Qrprii0( (AS c-#-11q01691W52A,12J-,