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- <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address <br />(02V \ (pER) <br />APN <br />6 4( Vfoe-T WA,-\( <br />Supervisor District <br />City <br />ID-c-ocAL-cDR <br />State <br />cA <br />ZIP <br />q6rW Ce <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 <br />If 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 />*Billing Party .Facility Owner XFacility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />v\A-12_t_O N <br />Last name* <br />b0 Ni. ZAccE_Z _ <br />If contractor, indicate type and license number <br />Address <br />t t?)\ I---- ACAa P\ 1D—- <br />City <br />S—CIOC—Ter \t, <br />State <br />CA <br />ZIP <br />C'4 Z-05 <br />Phone <br />Y/%5 %?-051 ' 6 <br />Phone Email <br />d5 kCCVAnbf-Pc)codo k b 5 97S0 <Ao <br /> <br />i \101c3\.‘ • C-corn <br />_Fii p 0 <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor,•t te type and license number <br />Address City State ZIP <br />Phone Phone Email <br />4N A icl <br />IV <br />i <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner ractor V <br />inris. , d type <br />0 Architect <br />PAYMENT <br />fteetiVtb <br />First Name Last name <br />Address City % Sta <br />ZJUN 0 5 2024 <br />Phone Phone Email <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTA1 <br />HEALTH DFPARTMENT <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 ass ciated 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 an <br />Standards, STATE and FEDkIIN,laws. <br />APPLICANT'S SIGNATURE: <br />be performed will be done in accordance with allSAN JO QUIN C UNTY Ordinance Codes, 1 <br />DATE: S -OCe I 11 <br />XPROPERTY / BUSINESS OWNER <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 COUN 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 B Aser61 To <br />0- <br />AID <br />Of 0- 141\ W-145— <br />Linker i 0 <br />bate <br />6C-c- )--f-t <br />PE <br />'‘ (-1i 14 <br />Pee <br />1,7)5 , <br />R <br />lq al+ 1 <br />Nnmhern <br />ct. <br />ATOR MA AGE 0 OTHER AUTHORIZED AGENT <br />Title <br />v Ali