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>11;i3illing Party ilacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name \ j , i <br />le_ VI. 0 k 6k-'r <br />Last name ,t. ( i <br />a c4... C".... <br />If contractor, indicate type and license number <br />Address - --..s S I' <br />City terzie4 State <br />C 4 <br />ZIP q , <br />Pre <br />0.5)8U--1 `fc <br />Phone Email <br />n KW d <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 D ZIP <br />© FIVE. i Phone Phone Email <br />HIM ) It 9.194 <br />I=1 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address <br />2Z—— 3-r I.-s 5+ , <br />Citttrek , <br />( <br />State , ki______ <br />C.-- <br />ZIP / c2- *--0 <br />APN Supervisor District <br />Type of Service <br />Requested <br />/1!Pwlication for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />N tw C ro C LA-<5 tt <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />YBilling Party p Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor <br />ENVI <br />101 Archilect. <br />1A lONMENL HEALTH <br />PERMITISERVIES <br />If contractor, indicate type an icense number First Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL>JA 71 ---=- <br />APPLICANT'S SIGNATURE: DATE: Vc2 KAS4 <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <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 at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Accepted By,., Assigned To Linked FA ID <br />Date <br />Lk, <br />PE <br />s c 0 <br />40 ?- <br />Record Number A-pv.00513 <br />?IVA 0D36'0