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A New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />_ <br />L WI WA. L t L' t U.., t • 1 fk 24LS (Airtil Cha 7 ( 1/ <br />1(43q Ai t4 Dor4cto 5+ 11/64-ocie-i-ovi ne Cfi .95206 <br />APN Supervisor District <br />Type of Service <br />Requested <br />X Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />g Billing Party V] Facility Owner ,Ydf Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />,, <br />)4 \. <br /> <br />6( . uao IMF C c(ccfrit(5 If contractor, indicate type and license number <br />hit-1--chltilluir. <br />Phone <br />)6) (050(taVet <br />is 5-(--acv(-0 <br />1Y , (0/1 <br />MP ,4 <br />lewq52. IC <br />WIC170 —6250q <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 />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />and lice841) <br />'"I9141&•A . <br />Pitee i <br />ZIP A/Et <br />JAN 29 <br />First Name Last name If contractor, indicate type <br />Address City State <br />Phone Phone Email 2025 <br />sky JoAn, , CAI. -..villo ... <br />ON Nry <br />t BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that alrsitelA OEN VAL <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on Z/Vj <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 anrLFEDERAL laws. 5- <br />0 PROPERTY! BUSINESS OWNER <br /> <br />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 <br />:sec c c. <br />Assigned To Linked FA ID <br />Date <br />Qn 1 2-C1 t 2 025 <br />PE . <br />\VD3 <br />Fee <br />4n-2.0 <br />*Confirmation <br />Record Number <br />Ap2501551 <br /># 1 1 5)....cyls---Cove: Payment <br />Received By 6 <br />0 <br />0 Cash 0 Check # <br />k <br />Rev 07/10/2024 <br /> <br />POSDb3201