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"N ew Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name 1 <br />1-5 V 1 '5 (3' L.)e,e..+27 <br />Site Address 1 <br />0 0 rj r NI CAA'&1 PA-Vt_ <br />City State ZIP <br />APN Supervisor District <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 />c -ro '6 <br />If mobile food truck or <br />pumper truck <br />License Plate Number i 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 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />c Firi i;I:me <br />0. <br />Last name <br />)C Of (1)--Tocy- <br />If contractor, indicate type and license number <br />Addres City <br />4)- \-Cdt -CriA i <br />State <br />CA <br />ZIP <br />q2C; V 60f-D Pc ty\4i-NA 0\pe <br />Phone <br />.209'- YO5S -9/ <br />Phone <br />'7';.6t <br />Email <br />511 e-l'IAC i 6U r 67 P COTIGI. i i (W7 <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 />_ <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor I:iitect tlik <br />First Name Last name If contractor, indi ate <br />• <br />e an lic e <br />Ztr-Pli° Address City <br />Phone <br />State <br />Phone Email <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL o APPLICANT'S SIGNATURE: <br />)KIPROPER-Pi'/ 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 Ordinance Codes, <br />laws. <br /> DATE: (943 1-L 7 ( 1 / <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 />rAYMr. <br />'Air Title Rec evED <br />at the above site addr reJiy uthorize the <br />JOAQUIN COUNTY ENVIRON WAI/1-1 <br />SANJOAn„.. <br />Accepted By Assigned To r-, i _ , le <br />- . uNitfp„,—,..y„ y rY <br />1-'sined <br />FA ID <br />errn 3 (° - ./41Eivr <br />Date PE <br />7 -3 1 • 2_-1 <br />.401#1.... Fee <br />it-' — Si Y Ce <br /> 1 ..-----" Record Number <br />taii-p4008.14 <br />Payment (}A) <br />Received By 0 Cash 0 Check # 6(C'onfirmation # 1 1861-2M6 <br />Rev 07/10/2024 <br /> 'NA ing-31-at -4- FR.2.‘te-Dss-s