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El New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />6-1 ti lac, s 404- i2p.ke_ pi z oc- <br />WV <br />1197, /A) ( ,ou k %-e, <br />NW <br />Supervisor District <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 1 VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />tkBilling Party 1S1 Facility Owner 'E Facility Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />11111.111.111P If contractor, indicate type and license number <br />twiimi.,,,A <br />0 Z - c 7 gricire - % eN s 11 , s A <br />7.0, ,,,,,,, (07 ril, <br />MP' <br />NW" 111011r <br />rilora-li-o4.1- <br />v.'close i:Licv <br />Coo.N. <br />0 Billing Party 0 Facility Owner 0 Facility Cont t 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 />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 />I, the undersigned property <br />HEALTH DEPARTMENT hourly <br />this application an <br />laws. e <br />or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />charges associated with this project or activity will be billed to me or my business as identified on this <br />that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />--e- for I - I cz - ZS- <br />El PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <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 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />PA Title <br />PeC41A., eArr <br />at the above site address, hereby aiRtAteb <br /> <br />JOAQUIN COUNTY ENVIRON I., <br />I <br />H LTH <br /> <br />eilitv ° 2025 <br />'it <br />Accepted By <br />a.Q. P. 4, d ).1q (: <br />Assigned To <br />i . <br />Linked FA ID <br />Elqoup, <br />i)k vp cpcp 8 Li ,*iiigmooviiveic04/41), DEr 7,44 <br />Date <br />OINI 2z213 <br />PE <br />L(002- <br />Fee <br />$n-z.eo 1 -4 . <br />Record Number krilfekr <br />Si2.25-00 "3- S 6/ • <br />0 Cash 0 Check # 2/Confirmation # 1 OH-5( L1.C1 .b Received <br />Payment <br />By <br />Rev 07/10/2024 <br /> KoN110