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0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner <br />Last name iiigC <br />0 Contractor 0 Architect PAyna <br />g" <br /> A <br />First Name If contractor, indicate type and license nu 01 <br />Address City State NOV ZIP 1 <br />3 2 <br />Phone Phone Email 4/1q& QUM/ C tiSJAL 0/v41 0( N D , &vra. <br />APPLICANT'S SIGNATURE: ICA U(11`C., A(e/nev2 <br />Standards, STATE and FEDERALlaws. <br />0 PROPERTY! BUSINESS OWNER <br /> <br />0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <br /> <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 />DATE: 3/i14,6 0,1y <br />/yr), <br />NrAf <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 />0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Erlity Name <br />Lhi nc^ Procluci- 5 <br />Stte,AddreSs i <br />I No L) it' J I Rd — iettY de i 0 0 ,5 <br />Stalte . <br />L A <br />ZIP (4535-3' <br />APN Supervisor District <br />Type of Service <br />Requested <br />,a/Cpplication 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 />liatilling Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Aisst Narrie R Las/ ripme , <br />A ( eirr:ta . <br />If contractor, indicate type and license number <br />Address State <br />17LIC ( )5 f (.1c Rcl City ( i <br />Hode,14-0 0.A <br />ZIP <br />q5 3V <br />Phone , , <br />( I 0 t teg --i:<(-10 <br />Phone Email <br />Chinon .cictIA:c45) i'CIO 04. Coin <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 />Accepted By Assigned To Linked FA ID <br />Date <br />11 13-29 <br />PE <br />I AS <br />Fee <br />4 I-12 a_ <br />Record Number it\y ..)4017)5 <br />Rev 06/12/2024 <br /> J7,2 ,c3O. /q/3-F702— <br />1V2CO2A3