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San Joaquin County EnvirOnmental Health Department <br />Application Form pv?pi ao(12. <br />Facility Name c <br />C 6 c <br />Site Address , <br />1 I i -2. a .X3 -\ -,•,') P, --,e <br />City <br />s \-ec-1,6--et\ <br />State ZIP <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments t( , -Ru-70 k'u e,•\_ <br />If mobile mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />,0 Billing Party 0 Facility Owner ,r1,Facility Contact <br />I <br />0 Property Owner 0 Contractor 0 Architect <br />First Name <br />1) \ <br />Last name If contractor, indicate type and license number <br />Address <br />$ he,.1 \-c).n V <br />City State ZIP <br />Phone <br />2-o1 -2-94 32-bt <br />Phone Email <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 City State PAO" ZIP <br />P.eepi.""ir ---.• Vpr., <br />OA? 7 — -"•44-, <br />Phone Phone Email <br />0 Billing Party 0 Facility Contact 0 Facility Owner AV 0 Property Owner 0 Contractor ' <br />If contractor, indicate type <br />N4N14/1 01/474,1/4 <br />„. <br />IOTA-1Oct ge4 <br />CO LN <br />a --pri,IterY 7-7447_ First Name Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />BILLING ACKNOWLEDGEMENT: I, the undersigned p ope or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT .url arges 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 applicat n a that the work to be performed will be done in accordance with a I SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br /> <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 />Accepted By -, <br />ctii Assigned To L c\ I _ v\ok v-e_ C <br />Linked FA ID <br />Date ,PE <br />2-f <br />Fee <br />ft <br />Record NumberaR <br />a4001c19 <br />*1t2. 0 b .cs\ • ig-192.1 4612, <br />TV.24tocogn, <br />