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p (2- 2OO Lf I4ew Facility 0 EXiSting Facility San Joaquin County Environmental Health Department Application Form FadlitY Name •• I. et I OYU Site Address -9- -19--AALRP19 ki unit e APN City n UY1T01y) ROM State CA ZIP q 53CIL- Supervisor District 0 Other TYPe of Service Requested s...0%-tpplication for Operating Permit 0 Consultation 0 Change of Owner 0 Repairs or Remodel Comments If mobile food truck or Pumper truck License Plate Number VIN Contact Types 'Nutted 0 Property Owner 0 Contractor 0 Architect 0 Billing Party 0 Facility Owner 0 Facility Contact Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect If contractor, indicate type and license number First Name . 2-(4 0 tk) pk trs Phone Phone Email • Last name —Aldi2itts-CISAJ<CL crao City .ffiCtirralii-li o use State CA- ZIP 15.3 C/J 11---).- --.--tA- a-1J-- 6_1!, c-r ea I r nin`f c cl . r-V 0 Billing Party jaltacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name ala loh Q-- i2ockika, _45h Last name Pir ruky,L,Q , If contractor, indicate type and license number Address 2-4 3 it) 4/0 p AS iN)QP-a-c City PinArtr4.— State ZIP 61 S-391 Phone ,i I Phone Email reptl* 0 r7S 11 PA e-be --1,-,161U, , C--0 rn-- 0 Billing Party 0 Facility Owner 0 Facility Contact JCProperty Owner 0 Contractor 0 Architect First Name L gi ,16; Ka. q4-)11 Last name If contractor, indicate type and license number A dress tki tjJr,s Allem-0 e City ota__________ State ZIP Phone Phone (1 2-5- 6 2- 2 -36 y Email cre_a-ti 0 )1 ctl - eie,6 , a ga ctiil ---- k c..9,771-- specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this BIWNG ACXNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project form. 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, DATE: i 1 VI Standards, STATE and FEDERAL law APPUCANT'S SIGNATURE: 0 OPERATOR / MANAGER OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER Title If APPLICANT is not the BIWNG PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Accepted.ay \ \CNC\ e ic!Lakte, PE \e5o Assigned To, Fee Linked FA ID Record Number AP2.LiGna, tct 0 Confirmation II 0 Med( N 0 Cash Payment Received By Rev 07/10/2024