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BIWNG AGCNOWLEDGEMENT: 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 la <br />APPUCANTS SIGNATURE: <br /> <br />4.1 DATE: S ) 2--1$ i VI <br />..„//1"1/tOPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BIWNG PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RFIFAU 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 />Title <br />0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facaftv Nam, <br /> Creations 4 celebration, <br />Site Address CITY State <br />App -141 R-0_1, ki nkverime riClUAl. 11,11LCW,_ C.A. ZIP c 1 5141_____ <br />Supervisor District <br />Type of Service <br />RetlueSted <br />Comments <br />.pplication for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />If mobile food truck or <br />Pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Fadity Owner 0 Eadlity Contact 0 Property Owner 0 Contractor 0 Architect <br />_ <br />Bilhng Party 0 Facility Owner 0 Facility Contact 0 Property Owner CI Contractor 0 Architect <br />---/rlidess "11-1‘6- <br />214 tt) Ho kins <br />Phone Phone <br />42s- -2-?6 # <br />First Name <br />/4'041 ue <br />Email <br />creatons4 57Pa • (.v-rri <br />Last name <br />City <br />r'1cxjstci, H t/Se <br />State <br />If contractor, indicate type and license number <br />ZIP <br />5.3 9 <br />0 Billing Party <br />- - I _,,,, . <br />..,119"Faolity Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last <br />—5 h al obh q, Pi 1 Cksika. <br />name rwat Ar If contractor, indicate type and license number <br />Address <br />2-pLih kill A\AP-u-e- -lin p <br />City <br />hIn tint-4 in Was ‘e <br />State <br />CA— <br />ZIP <br />4 r391 <br />Phone Phone Email <br />erect-h. onA Plebe 9-0-1 it , Cio rrL_ <br />Accepted By Assigned To Linked FA ID <br />Date PE Fee Record Number <br />0 Cash 0 Check N 0 Confirmation ti <br />Payment <br />Received By <br />. _ <br />0 Bilhng Party 0 Facility Owner 0 Facility COnt20 [..ErProperty Owner 0 Contractor 0 Architect <br />First Name <br />1,-- gi diiik-cL <br />Last narnketA <br /> AO j <br />If contractor, Indicate type and license number <br />A,2-lai <br />—rest <br />741 0 w -HD /tins 41E11" e tiletint-apl' <br />City <br />flowe i State ZIP <br />c4/5-39/ <br />Phone <br />42-5-'62-2 --. 33 <br />Phone <br />6 9 <br />Email <br />creathoms.4 f'ejej2841 • cRem- naca <br />Rev 07/10/2024