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FP'N 0001411 <br /> `�'lU!1� El New Facility ❑ Existing Facility <br /> r � � v <br /> San Joaquin County Environmental Health Department <br /> Application Form _ <br /> fr Facility Naive _ <br /> -��lue Gaos� ake Sno <br /> Site Address `�ty State ZIP <br /> IUD 7 Tena n Couv7 Hunreca cA (q62 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> �•� ( Fn [� CcSS 4 <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ElArchitect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name L u u r'-e h ast name r 0 r-) if contractor,indicate type and license number <br /> Address City State ZIP <br /> 1031 Tena ya court Han Teca Ch a533 <br /> Phone $G$ Phone Email <br /> 20Q -373 Lfiur2F- tJE L 0sa0C'P C4M IL cpM <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ity Cont ❑Property Owner ❑Contractor ❑Architect <br /> First Name Las a e If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone 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. f pp —y, J <br /> APPLICANT'S SIGNATURE: `� ` �� � .^-DATE: / O 12 p`y� <br /> ❑PRQPERTY/BUSINESS OWNE []QPERATOR�/fv1ANAGER [I OTHER AUTHORIZED AGENT <br /> RFI�C�IE r <br /> Title `/ D <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required I�ff nn <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby aT.R'h.&gRh& <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRON*WftQLTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. IJy <br /> Accepte�! Assigned To Linked FA ID <br /> Cat C_V_ j <br /> l= <br /> Date PE Fee Record Number <br /> �tvf--- AP2�fmm�2q <br /> it <br /> 1 O q )W 2 1, <br /> s K�-1 � /','� h rtd� r rn� 1 �•�S�-,�'t��C0�9�u 1 J <br />