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1=1 New Facility <br /> <br />IE Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name—. <br />Via os Ock5 i ,-; \-as -1-,,c-\-k.ALio.--5 <br />Site Address City State <br />SkTICNONCA CA <br />ZIP <br />(31326.6 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation lieC"hange of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number s R 61 0 3 a 0 VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />rsiBilling Party El Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Namq.-,‘ , <br />t Icto,\IDe...\\(\ <br />Last namei a <br />lvtiOnckei. V\escocoocta, <br />If contractor, indicate type and license number <br />Address <br />1 <br /> , 1 <br />5A<V\ 1-ooric '..14 <br />mail <br />_C) _ SA <br />City <br />Siric_V‘on <br />State <br />CA <br />ZIP <br />(62_06 <br />Phone <br />1-0C1- bAcl-cl 660 <br />Phone <br />. <br />E <br />cA\ % ckyl c kbo (A; s <br />0 Billing Party 0 Facility Owner ErFacility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name A <br />M Mie- 1 0%. <br />Last Rune <br />5aVIC-Vut2 <br />If contractor, indicate type and license number <br />Address Cit <br />Vt,c,‘ckty, <br />State <br />(A zi6iP5-24‘ 51,k014-) <br />Phone Phone <br />VC(' 6 c6CP-16 0 <br />Email <br />5Ck,V1 (Alf 7 . l(141;70Ct ot -54 ti @.- Cl\l')0\1 1,,rdtv <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: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />a 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 all site and/or project <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY ORAViriAt!des, <br />laws. i r. "KEAN <br />.z-Jo-1h Ikk- - <-4,---z_ 1-kr'v d-r-Z DATE: 0 3 - 0 ‘ -- 7.0 7-51kCElitr. _..S <br />OWNER 0 OPERATOR/MANAGER 0 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 />v C <br />MAR n ts <br />Title V U 2025 SAIV j n , <br /> <br />at the above site a ddrAtiaorp43 Othil., , i r <br /> <br />JOAQUIN COUNTY ENVIRdWaffigy ... "il. -- AtrTrmr- cNr <br />Accepted By <br />516 <br />Assigned To Linked FA ID <br />FA 130J.Co 53 1 <br />Date <br />3-(-5 <br />PE looa- Fee i 1 -7 2 (at ----, Record Number sRa5009o0 <br />0 Cash 0 Check # w Confirmation # 041-186C.Q9:7 <br />Payment <br />Received By aa <br />Rev 07/10/2024