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El New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />one. Yosemite <br />Site Address <br />965 E Yosemite Ave Suite 7&8 <br />City <br />Manteca <br />State <br />CA <br />ZIP <br />95336 <br />APN Supervisor District <br />Type of Service <br />Requested <br />RI Application 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 />EI Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />13 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />S a frx 0-6, 0, ctIA.; 14 CC? LA II 4-1j <br />Last name <br />CW4 I'C' 'e• a c...c1(4. cot-i-i'co ii <br />If contractor, indicate type and license number <br />Address <br />Po 130 g 2_1 3o3c, <br />City <br />5f ock-i-s k, <br />State ZIP <br />95-2.1 3 - ct 03c <br />Phone iihone <br />r ii ko Fr — q 3 q <br />Email <br />5 )c.z.c - otp -..e.• %cr., c . 4- te.-1- <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 pi el v <br />r 44, <br />First Name Last name If contractor, indicate type and licensJICj <br />I <br />Address City State ZIP OCT 2 3 ' 4 <br />Phone Phone Email SAN j0A ,, , <br />ENviiR'''L'IN cc k ONro A <br />1-TH D EnN <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <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 />c-fiet <br />) cr--i T I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or pro rt <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 applicati and that the w k to be performed will be done in accordance with all SAN IOAQIJIN COUNTY Ordinance Codes, <br />laws. <br />(441 //// .2i6 414•11V DATE: <br />OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />PARTY, proof of authorization tp 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 />TY ,•45?9 ' 1)I MC-40r Ck- <br />Title 0 pg.fik4.0244-5 <br />at the above site address, hereby authorize the <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />N <br />ED <br />24 <br />UNTy <br />AL <br />ENT <br />Accepted By <br />(1-0.4f(L4 t.-g- 0 <br />Assigned To ....27(V‘,‘„t4" e Linked FA ID --- j\jeAAJ <br />Date PE ((c-,..2.--. Fee Recor,ccNumber . , <br />0 Cash Check 0 i tZeZ, 3g / / 0 Confirmation # <br />Payment <br />Received By <br />Rev 07/10/2024