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El New Facility fP Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name n .1 v A_ f) 0 )--) jc4 f ki 6,-10 ci_, 1 hc <br />r , <br />.Site Address City <br />i ci L 1 S -3-E-• I_ DA o _S-.- _c-1-00( row <br />State ' , <br />c )1- <br />ZIP1 <br />qC9")( <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation tit Change of Owner 0 Repairs or Remodel El 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 />14Billing Party K Facility Owner T./.1 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />s i-IL6:-) IV -: : Last name ,,, 9 A i 1, <br />W C't-Zr I <br />If contractor, indicate type and license number <br />Address <br />/ <br /> 0 <br /> <br />City rh 6.xteca_State c 4, zii, <br />Phone <br />CiZL) .SCS2e 9 I <br />Phone <br />c-, <br />Email <br />1114-tr:-A i'v' Pee 51" Rs-s-e cci--h-i.-4 .Ce=7-t <br />El 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 />APPLICANT'S SIGNATURE: <br />Li 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 the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />laws. <br />..V ALIO irv Dii i) )n/ 6) Y\ DATE: 0 1 ) 2- ?" / 'Zc' 2-S <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 />4Z fri <br />C i Title <br />MN , .,,, <br />at the above site address, heretvouthorizethi 2 <br />JOAQUIN COUNTY ENVIRONMENT*ali <br />itolo.,,ftONLIV COti <br />Accepted By <br />V;CRI.Q. P <br />Assigned To <br />(2„ kO.AACAI CIL t.' \ • <br />Linked FA ID 'v174 <br />AlW(1% 2-b(o <br />Date <br />2.5 <br />PE <br />i (C (k 2- <br />Fee <br />$ I i2 .0T S 17 ,----- <br />Record Number <br />SR25008t3 <br />El Cash 0 Check # <br />-.14---q_. <br />liConfirmation # 1g GCB <br />Payment <br />ei Recved By <br />Z7if <br />leo) <br />925 <br />Rev 07/10/2024 <br /> <br />FRV0 tIRp