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0 Architect (contractor lJ FeelittyCalteet 0 Property Owner Facilltre Owner 0 Silting Party Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />If contractor, indicate type and license number <br />J'aikasavgcbt-t- ca't etv IDS Pgt.251 Last name First Name David <br />City State ZIP <br />10 ,6,0,454, eA <br />er5rtagsv 0 St <br />Email <br />1.191/441it 5 . ‘4. di".111111111 - <br />Address <br />14A4-1,2,1- st qq 30d1 <br />Phone <br />"- 34 -11SOV <br />Phone <br />Accepted By 0.7, <br />Date <br />San Joaquin County Environmental Health Department <br /> Application Form 1-1V2-LIWV71 <br />Facility Name <br />ik-451-11)c 61>t, CIA )-P r-Tix LL_ -‘15 .51/AkieL <br />Site Address <br />ij • Me -/-e At. _ <br />City <br />444,./1(7.4 <br />State 04 <br />APN Supervisor District <br />Type of Service VApplication for 0 Consultation <br />Requested Operating Permit <br />0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or I <br />truck <br />License Plate Number VIN <br />pumper <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 <br /> <br />Phone Entail <br /> <br />t C _ <br />I <br />0 Billing Party 0 Fa ty Ow r liVF,Iiity Contact 0 Property Owner 0 Contractor 0 Architect P4 <br />4 <br />and license riiree <br />First Name st name If contractor, indicate type <br />Address City JON State I ZIP 0 , <br />- 43'4Arj 114 <br />Phone Ph)( Email ole <br />o- <br />14 EArki 4 QUA/ 1 <br />fa <br />, BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or proirMr4i... <br />speofic 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 />also certify that I have prepared this applica <br />Standards, STATE and FEDERAL lawf.tion <br /> den work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />APPLICANTS SIGNATURE: <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER Cir OTHER AUTHORIZED AGENT C <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 ENVI 0 ME AL HE L <br />)DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />1Iu\ <br /> <br />k A <br />E <br />024 <br />DATE: DATE: 0513012-Li <br />Linked F <br />5 <br />Fee Rem eTD <br />4 /C( <br />afd 67/-2,0p/- 00b02,6' <br />he'