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Last name <br />City <br />Email <br />0 Property Owner ractor <br />tractor, indicate type and license number Last name <br />60\4 )co one <br />ZIP State <br />DATE: <br />0 Architect 0 Facility Contact 0 Facility Owner 0 Billing Party <br />ZIP City <br />0 Billing Party <br />RPeAcYemiEvNE r Email Phone Phone t <br />0 Ard-AUG 20 2024 <br /> <br />- OA <br /> <br />If contractor, indicate type and license &COUNT <br />HEAL RENTAL <br />Tli DEPARTMENT <br />Property Owner 0 Facility Contact <br />First Name <br />SPirer <br />Address <br />LI Contractor <br />El t Name N /0 <br />3 ,. <br />tk <br />F cility Owner <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 />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 law <br />APPLICANT'S SIGNATURE: <br />y_f_)ROPERTY / 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 />0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />A(.1,r\ 9— C--Q-0 2D C, <br />Site Addres <br />A <br />s <br />M D \ -4 a C2 <br />,City <br />NA.0 <br />State ZIP <br />APN Supervisor District <br />Type of Service <br />Requested <br />XApplication for <br />Operating Permit <br />0 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 />- _ <br />0 Billing Party 0 Facility Owner .. - 0 FadlIty Contact <br />- <br />I:l Property Owner Cl Contractor . 0 ArchRect <br />1141111ing Party -'1Qacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />6 L.l.-Lj 1-1 -- <br />LK a me <br />A (2-4 <br />If contractor, indicate type and license number <br />IdEs <br />'.'1 l'A O C./1 (2— <br />City <br />V\ -T-Ge <br />State <br />C r- -P <br />ZIP <br />QrS--.6-1 A .. <br />Phone <br />09 q2-3 3 <br />Phone Email <br />IP. <br />Accepted By Assigned To <br />G`te't <br />Li AID _I <br />i <br />Date <br />estirt (II <br />Fee <br />$4 <br />114.,") it Record Number <br />_ f\99-41)(1)8 <br />la ... . <br />, <br />COI r 6 ... --' <br />_ <br />Received By <br />paZdt (5\4tyte._ ;p11),Dd et <br />05\4 It so-39h '3- 4 <br />Rev 07/10/2024