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10' New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form W2LtO33Z <br /> Facility Name / <br /> Site Addre City State ZIP <br /> Lodi I4 2 b <br /> APN Supervisor District <br /> Type of Service 51wPiplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> N e.�..7 t`-'1F� �r'�.r1Yu1.4'r"e�! i h S�-G�►11 S�[u.t,S C:.o..u�.4y <br /> If mobile food truck or license Plate Number VIN 7 f <br /> pumpertruck ' ('eq �.IzAaA <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 7 <br /> ❑Property Owner ❑Contractor ❑Architect <br /> First Nam�i1{ �r�r� Last name � If contractor,indicate type and license number <br /> Addre � 1 v � ` Cit State 21P <br /> Phone- Phone Email 1 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name if contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑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: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 s. <br /> l�� <br /> A;'PLICANT'S5IGNATLYRE: DATE: -._. �` A' <br /> ❑PROPERTY/BUSINESS OWr4 ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT ��i;VNT <br /> Title E J) <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,4y A19or he <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENV4"1J NTAL HEAL <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. AQjJ <br /> --�— N N <br /> f Ar-+•••'ed By [ff Assigned To Linked FA ID pgRT <br /> I _ Te- t C• t=ra rlusc it R- M�Nr <br /> Date PE F e r. cord Number <br /> +1m31z� k(0Q2) -}2,0a) 1 P2�4 <br /> aR <br />