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0 New Facility CI Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form W2500303 <br />Facility Name 0 _. 1) _ 1 _ <br /> <br />VI ' Gi il 4 '7j 11,4vt(-) LP <br />Site Address <br />2__D ‘, .-.1,011 2 . C Art-e.. <br />City State ce,,,,, ZIP of 52-0R- <br />AP N Supervisor District <br />Type of Service <br />Requested <br />'Application for <br />Operating Permit <br />X 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 <br />LA i -2, -1 <br />VIN le -i-NIF-2.1S-iri <br />contact Types Types 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />required <br />Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner I 0 Contractor 0 Architect <br />First Name, „, <br />L <br />j <br />lvl <br />,_, <br />U D <br />Last name <br />Ku c ()a rvLot 5ci ot ( evi ,D If contractor, indicate type and license number <br />Address City h..ej <br />-2_0 1 MAC Ac4\e, <br />pz.. State , ZIP__ <br />ci S -2 C.573- <br />Phone Email <br />O 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 ID Property Owner 0 Contractor 0 A rcifity4e <br />itC -111 7. First Name Last name If contractor, indicate type and lice Ofe <br />0 <br />Address City State <br />SAN <br />ZIP tyl4 1 4 <br />_ JoA, 2025 <br />Phone Phone Email ileoliTROAfitf <br />tAit,," 'WU/iv <br />COUN,_ <br />1.1 OPPS41:4/ i r Ad A, <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or proje?tr <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 pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />"'APPLICANT'S SIGNATURE: \IL' Ltoi Standards, STATE and FEDERAL I <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER U 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 oda p. Assigned To <br />Lid cl i a 8. <br />Linked FA ID <br />v: AU) apq sc. <br />Date PE +to 5 Fe - <br />.1-12_ <br />Record Number <br />APz50/467 <br />0 Cash 0 Check # <br />t/ q Confirmation # H4155-6-77‘„ i Payment <br />Received By <br />V DATE: 01 2 f52,c- <br />Rev 07/10/2024