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\ <br />Lint Id FA ID <br />1\ E <br />_Record Number „ <br />3 <br />) <br />Accepted By <br />C\ NC-1CA.(Tc* <br />AssignA T. <br />Fee \----t---- Date <br />Rev 06/12/2024 (12- <br />/g.1.7 .113o6 <br />2.44 00 316 <br />Facility El Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name New de)ruscaivry,..l-e-r•r\ wolra)c.t_Sdrool <br />Site Address <br />31tA C) es S . ILO c4er RA • <br />Di_s+ • ' bdtc% OrkAri-e-r \-i .S • <br />ity <br />—5". a CAI <br />State <br />Ch <br />ZIP <br />CISC) 4 <br />APN Supervisor District <br />Type of Service <br />Requested <br />VrApplication for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments OPexati n9 9..ex rni i• : lieu.) Setvice kra a ftos) V?-ET, 614 LI <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />CrX14,0911P#V4'07.', <br />reqtar0,,i4:110' <br />'DPä N, <br />.14 . <br />0 fecihty Owner P Facility Contact 0 Property Owner 0 Contractor D Architect <br />rin Billing Party 0 Facility Owner /Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />dallai <br />Last name <br />to,t.Acttyclaie <br />If contractor, indicate type and license number <br />NI A <br />Address latl S1400 .3.1<05--e-v- c2.6 • I n-aCy <br />State ,cpt I ZIP , <br />, <br />Phone <br />204t1t-ib9ietc1 <br />Phone <br />x 1 t2,5 <br />Email t I, <br /> "il avdevdoastts..)n 'f-,c • 13 Y5 <br />0 Billing Party 0 Facility Owner <br />— <br />0 Facility Contact 1 0 Property Owner 0 Contractor 0 Architect PA IF <br />First Name Last name If contractor, indicate type and license nu • <br />Address City State ZIP <br />4 U& 0 <br />, <br />Phone Phone Email SANJ <br />EN OA <br />Qui <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 1 City <br />I I <br />State i ZIP <br />Phone Phone 1 I Email <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 laws. .,.----\, c? <br />APPLICANT'S SIGNATURE: ( ,--I <br />( <br />DATE: 1 0 <br />...,. ( <br />0 PROPERTY/ BUSINESS OWNER l',.../1.i ,L.1,0PERATOR / / OTHER AUTHORIZED'AGENT 1\1td—r:11-1 WIN D i /-2...LA-17 r <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 />2024 <br />co,N