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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> n i ► a r IC e-t <br /> Site Address City State ZIP <br /> S. Mar► osa Rd. VO-VA r.R q 5aO5___ <br /> APN Supervisor District <br /> 1-7110006 <br /> Type of Service ❑Application for ❑Consultation 24charige of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility OwnerT <br /> Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party ST Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name U Last name If contractor,indicate type and license number <br /> Address CityL4n— <br /> DState ZIP72S �� <br /> Phone Phone Email <br /> 1Z5-Jq D- v �movrF .Max <br /> ❑Billing Party ❑Facility owner ❑Facility Contact El 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 ❑Co PAYMEN ❑Architect <br /> First Name Last name if co A kc 9 and license number <br /> Address City StateUCL, ZLIP <br /> SAN dOAQUIN CCU ry <br /> Phone Phone Email ENVIRONMENTAL <br /> HEALTH E)EPARTmrta <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 laws. 1 -JCL <br /> /, <br /> APPLICANT'S SIGNATURE: oIU?L , 1I14, DATE: LZ �3 z <br /> Cl PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑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,geotechnicai data and/or environmental/site assessment information to the SAN JOAQU{N 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 B Assigned To Linked FA ID <br /> y Shannon g CIaudia, h4_ A001rD324 <br /> Pate PE Fee Record Number <br /> 17a SRZIL40073 � <br /> Payment <br /> Cash ❑Check 4 ❑Confirmation ft <br /> Received By <br /> Rev az/1o/zaza `�C , <br /> III <br /> �2 <br />