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U New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />\l'•, f (%Q HCD 0 kl\ Lk:\ & i'vt__ . <br />Site Address , 1 yv <br />()1 /4ALIDe__e_ 1.___v. <br />City <br />1 D ' <br />State <br />c..- zi;?' S-IL'I ° <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 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 />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First N <br />\ <br />Last name <br />fliV\I\d I <br />If contractor, indicate type and license number <br />Address <br />I) \ <br /> <br />I k 0 0 Mikt' S\i\r)t lk() e--- <br />City <br />VC-CA 11-lie <br />State . <br />c I/A- <br />Phone,-- Phu vr(A , 1 <br />it <br />Erwil , <br />I- if '‘AIW 0 V4) nrheit i I C-0 tA._ <br />0 Billing Party 0 Facility Owner 0 Facility Con-tf6ct CI Pro[(e)X,/ 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 />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 />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 />, <br />plication,and that the work to be performed will be done in accordance with all SAN JOAQUINS91.1-NTY Ordinance Codes, <br />la . <br />DATE: z--- 0 - 1 0 .C1 \ /44 Y4,7z, , , <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 />Title <br />' 8 I <br /> <br />at the above site add ereby atittpris <br />JOAQUIN COUNTY ENVIR aittS0EAL1W <br />He44 /ROZ A/co <br />7.1/4p4r/V7 -4417)' <br />Accepted By <br />\i i d a I ?. <br />Assigned To <br />Fro nb scc) R- • <br />Linked FA ID 11041/tr. <br />FA 0000315 .4r <br />Date <br />02-111:0 2Cb26 <br />PE <br />VoCD3 <br />e Record Number <br />0 Cash eck # V <br />1 or 0 eonfirmation # <br />Payment <br />Received By <br />Z <br />Rev 07/10/2024 <br /> <br />W010/3°1