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f <br />XNew Facility El Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name Ei vt, ..1._(1a,vt.c/k „too sotto I <br />Site Address mu, D <br />dk VV-4,(8 <br />I fitfitffi ro State/7i <br />ZI,5-32 161 <br />APN Supervisor District <br />Raini-A ti-so <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />El Consultation 0 Change of Owner CI Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party "(Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party 7Facility Off uso 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Fir Name <br />tAIZ , <br />Lasit&arKihitsW/"/ If contractor, indicate type and license number <br />Address <br />0-2-3 1 5 1 Raytato . <br />City State erk . <br />ZIP <br />95-2dy <br />Phone <br />Zif-71 fi 461C <br />Phone Emai <br />PAr I) OA, 1 le‘12-- <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 I 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 Ii s <br />Address City <br />Email <br /> <br />State ZIP V <br />Phone Phone 2024 ,v Jo ji <br />Iv, NV/R. Li/ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that-511401v .. ... -.141 N7. <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly chargesi sociated with this project or activity will be billed to me or my business as iden .... i 4/.. <br />form. <br />I also certify that I have prepared this application a d th - 4iriiiiik . . - . - orrned will be done in accordance with al SAN JO QUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />31) APPLICANT'S SIGNATURE: DATE: -0, <br />I <br />"ROPERTY / BUSINESS OWNER 0 OPER i TOR / MANAGER 0 OTHER AUTHORIZED AGENT le <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 „ Assigned To i , L_ -v-\\r\ci. r e s <br />Linked FA ID <br />Date <br />' \ • a V' <br />PE <br />\o02 <br />Fee <br />1 -4-2_ — <br />Record Number <br />A P241-Ctrotao <br />D Cash 0 Check # <br />iyment <br />onfirmation # igs - 6 c/66.E* . neceived By a <br />l&A <br />Rev 07/10/2024 <br /> <br />W2.ti