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tnt Lob) Sue CA- <br />San Joaquin County Environmental Health Department <br />Application Form r.lity Name sAa-es <br />Site Aadm. 1 us Le& -'b <br />APN Sven me Dutnit <br />t\s1 Comm mu <br />YIN License Plate Number Ifmilefcdk or <br />pumper truck <br />Architect Contact Tvpm reqtured • Hahne Port' • Facility Owner • Facility Contact • Property Owner • Contractor <br />Billing Party <br />First Name <br />Address <br />Phone <br />State ZIP <br />Phme Email <br />Last name If contractor. indicate type and license member <br />Baling Port' <br />• Facilny Owner • Facility Contact • Property Owner • Contractor • Architect <br />Fern Name ) <br />Addre' 6P-S 1-60/-0 .4( <br /> Lau name Jr If contractor, mchmte type and honor number <br />State CAs_ ZIP Q ) <br />Phone Email <br />1, avy ("13 ?ci 1K h.<1,0-er ret.)0.-2,1 <br />Facilary Owner • Facility Contact • Property OWnCr • Contractor • Architect <br />PROPERTY; BUSINESS OWNER OPERATOR MANAGER • OTHER AUTHORIZED AGENT <br />Title <br />If APPLICANT is not the BILLING PARTY. proof of nuthonzation to sign is required <br />AtTHORTZATION TO RELEASE LNFOR3LATION: When applicable, I. the owner or operator of the property located at the above site address, hereby authorize <br />the release of am and all results, ,geoteckuncal data anther enviroomentalkite assessment information to the SAN JOAQULN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. es soon as it is available and at the same time it u provided same or my representative <br />ZIP <br />Type of Service Ftequmted Application for <br />Operating Permit <br />Consultation • Change of Owner • Rrysairs or P.emotlel <br />CLASS. <br />Other <br />Architect <br />Ftrst Name 1<c_t,...'t Last Dame t-IEL CAA If contractor. indicate type and license number <br />Address [Co 6.-1.11 <br />Phone 2 --9`2.06( Phone )-0 ,6(2-3 -3212 C.1c1,4(.14-ci_aad <br />Timlny Owner • Facility Contact • Property Owner • Contract, <br />Sue CcA_ ZIP <br />A"'Vw4 BY CI tX v- ec ce <br />Dote 1-'7-z* PE I6'" <br />Assigned To TZ.LA Linked FA ID <br />Fee I <br />Record Number qp.2_44/4)-.12:5‘ii <br />BILLENG ACKNOWILEDGENCE_VE I. the undersigned property or business menet operator or authorized agent of same. acknowledge that all site mokor project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly diarem asseetned with this project or aetiviw trill be baled to me or my business as identified on this form_ <br />Standards, STATE end FEDERAL laws <br />APPLICANTS SIGNATTRE: <br />I also certify that I have prepared this application and that the - be performed will be done in accordantm with all SAN JOAQUIN COUNTY Ordinance Codes, <br />DATlEt <br />W1-100SL-11-1