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U New Facility L Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form PR o2 <br />I, -- Zati -, ()I-01es? <br />i--9, na/(7-#1.t.• ,RD <br />APN Supervisor Distri <br />.e--.6. <br />,Reli A--‘(/C4-/vt <br />.0*9A1 pre A gr-2-eP‘ <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 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 )4 Facility Owner g Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />If contractor, indicate type and license number <br />mir,ti_ iiia 1 /00 /11-4/4 wistlAr e4,4//v4. w Avt <br />- <br />.00 eilici <br />iir.),e7.0ty.i- Phone <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 />Pm, <br />a II, ikrr* kelp, <br />11.-Ceitt I <br />PPEE1 I 0 2025— J r, <br />C0111 Co EAR;IQUIAI . ,E44/ .7. . (mild <br />First Name Last name If contractor, indicate type <br />Address City State <br />Phone Phone Email <br />c s AA, <br />Af <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />, <br />0 PROPERTY / BUSINESS <br />If APPLICANT is not the BILLING <br />AUTHORIZATION TO RELEASE <br />release of any and all results, <br />DEPARTMENT as soon as it <br />I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that ailllitg ct <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifie tVZ <br />this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />law,s. , , <br />,-/; r) / )'d <br />OWNER 0 OPERATOR ANAGER 166 OTHER AUTHORIZED AGENT <br />PARTY, proof of authorization to sign is required <br />INFORMATION: When applicable, I, the owner or operator of the property located <br />geotechnical data and/or environmental/site assessment information to the SAN <br />is available and at the same time it is provided to me or my representative. <br />Title <br />at the above site address, hereby authorize the <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />Accepted By <br />Terf C, <br />Assigned To <br />Ka clecume L-, <br />Linked FA ID <br />olosTi88C/q <br />Date <br />02.12010(7)25 <br />PE <br />1(42, <br />Fee <br />V 7 2.0T <br />Record Number <br />SR2.5occ,8(02_ <br />0 Cash *Check 0 Confirmation # <br />Payment <br />Received <br />Rev 07/10/2024