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2q03
<br />..,,2<w Facility D Existing Facility
<br />San Joaquin County Environmental Health Department
<br />Application Form
<br />Facility Name
<br />New (jekuscuLer, .k..2_,m Scilool Dis+ ' Ue-itc, cv,k-kr-r__. Site Address
<br />31140 0 R .140s4er. Ra
<br />31-11"*Plity
<br />. ! State 'Tracy c ik ZIP
<br />9530 4 APN Supervisor District
<br />of Service Type
<br />Requested
<br />ji:( Application for
<br />Operating Permit
<br />0 Consultation 0 Change of Owner 0 Repairs or Remodel I 0 Other
<br />Comment
<br />0 Pf-rettincl Pur N-1 i i- ". lie to Strvi Le 6-e#1 /4 N6 f-toD ??-Vf, 614 LV Sg-VS)
<br />If mobile food truck or I License Plate Number i VIN
<br />pumper truck I
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<br />•
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<br />s .....
<br />' . '13 riatitatitait 'itti•fifOriertivOwner
<br />-. • '
<br />artilitria.-- ,
<br />'
<br />. r 1:1 Atchitect , e.. '...ii.. ,
<br />1
<br />4 Billing Party 0 Facility Owner /Facility Contact 0 Property Owner 0 Contractor 0 Architect
<br />First Name
<br />( l(ndki
<br />Last name
<br />LCOA CAtYCI ale If contractor, indicate type
<br />M P
<br />and license number
<br />Address
<br />It()() -1 S. l<OS4tv- R_d • I Cl State State I ZIP,
<br />6 -CA 3 6 Li
<br />Phone
<br />204111461am
<br />Phone
<br />NkIt5
<br />Email i
<br />Ilciuderdolti&n \es_..erel 1
<br />0 Billing Party 0 Facility Owner 0 Facility Contact ' 0 Property Owner 0 Contractor 0 Architect ,.
<br />
<br />4 11 to 01:14
<br />, First Name Last name If contractor, indicate type and license nuntirC' C
<br />Address City State ZIP AUG 0
<br />Phone Phone Email
<br />6A N J0,4 Nv./,,„ Q U/, , f i'E,A/ _,.. --cON44 --, •, . 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect
<br />1,
<br />First Name ... .... Last name i If contractor, Indicate type and license number
<br />Address : City State .
<br />i
<br />ZIP
<br />I Phone I Phone Email
<br />MN r 111,0
<br />8 2024
<br />-00N, Efok Y
<br />Rritgivr
<br />BIWNG 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 wori< to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,
<br />Standards, STATE and FEDERAL laws,
<br />APPLICANT'S SIGNATURE:
<br />0 PROPERTY! BUSINESS OWNER
<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 representariye.
<br />AOPERATOR /
<br />DATE:
<br />91 OTHER AUTHORIZED AGENT t1Ui-r-1-ti 6%(.\
<br />Title
<br />
<br />, *,1.' 7 ' t' • , I -,
<br />
<br />ist - ..“` -.... - ''....T., Atb,
<br />i s c_ • n, \r‘0\.( e Ne 0_3,
<br />Iii*,to., ., ZI, '
<br />Fe,
<br />\ "9-`2_---
<br />aist4mbeakcis6ck
<br />Rev 06/12/2024
<br />
<br />s'6 r73o6
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