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rxECE/v6 <br />San Joaquin County Environmental Health Department <br />Application Form sA"J <br />JUN 13 2024 <br />°Acunico„,, <br />----F4M7PPmAZT4NT '17\ALL <br />_aC APN VALmta_nas <br />Supervisor District <br />'-' <br />_c_ei.,.. 15 <br />g - <br />F <br />—T-ype-- of Service <br />Requested _ <br />0 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel <br />check <br />• <br />5 2- <br />license Plate Number If mobile food truck or <br />pumper truck <br />omments <br />Billing Party 0 Contractor 0 Facility Owner Fadlity Contact 0 Property Owner Contact Types <br />required <br />0 Architect <br />Villing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />F Name <br />1.a. <br />La name • 11V1 i 4I <br />If contractor, indicate type and license number <br />Address <br />6 2. 0.- • , IIU <br />City <br />Imik ff)f______C8 <br />a %, (a_tikoN\-. <br />State 15,3aci___ <br />Phone <br />/2v1- 6A. 'MI <br />g hone <br />iv i tke.,9 coin <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 ZIP <br />Phone 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 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 he wpç to b erformed will be done in accordance with all AN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDE <br />APPLICANTS SIGNATURE: DATE: 06/06/2 4 <br />‘WROPERTY / BUSINESS OW 0 dPERATdIt / MANAGER 0 OTHER AUTHORIZED AGENT <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. I 2.i(_p <br />Assigned To <br />010 <br />Accepted By <br />6ifb <br />c)) n -6 m -h tir) 1=1 z--70 lq 354 172_7Dtli-2____ <br />aq \ o I re° <br />oLua Linked FA ID <br />ReVitTootiiS