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E New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />, <br />Facility Name b e, oil S IA, I oqr k.E,' f <br />Site Address <br />7)J- 5 Axt_i r) R A <br />CU, <br />A 0 ( LA/Dv ) <br />State ZIP <br />/o <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />5.Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments „ <br />Lot Q en 't e k-N c-e s-kue cDnsk_LQ-1--ck_kion <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 />A Billing Party g Facility Owner ,Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />Zi_Z ZI/7 TJ-r(<- <br />Last name , If contractor, indicate type and license number <br />Address City c, i State ZIP <br />Phone / <br />`ao c i —:>i'. 17- 9z-/ <br />Phone / <br />?< J <br />!mail • , <br />ini,)//17c„. X i,,f „,) a0Y\4.16( ,Co vv\ <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 />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / 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 al SAN JOAQ IN COUNTY Ordinance Codes, <br />laws. <br />!---/ -.—Z-.1-2 bi / ili DATE: V / & -D <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.d <br />Title 10* <br />at the above site address, he afailiks tne <br />JOAQUIN COUNTY ENVIRO,NM6NTAL HETLVO <br />1 ' <br />'34/v <br />2 <br /> <br />Accepted By ,.., , <br /> <br />-Se V V L, , <br />Assigned To . . <br />Lycl lcA P3 , <br />Linked FA ID do k oiCir , <br />.41/if? '4A/ C oivA4c. 0:1,4 <br />Date <br />NIG12-02.4 <br />PE ilo a 2_ Fee $ I 12.. OW , ( -÷Q . Recgtrcl_NLInter, t*-p,A1 riii. <br />nP2-474W/05 -civr <br />0 <br />0 Check # OVConfirmation # 1 Li Li if al...g. Payment <br />Received By <br />Rev 07/10/2024 co2/L4 xaecoi