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DATE: <br />Standards, STATE and FEDERO_Ja.ks. <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <br />IS(Billing Party S'Facility Owner lEeFacility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />IMV I 2 <br />Last name ....r.-12. tit j If contractor, indicate type and license number <br />Address City <br />(OS- 26 f-ol)o T laccorze,n 51-ock-f--oN <br />State cA ZIP ofszol <br />Phone <br />TLI) 225 - eN6 <br />Phone Email <br />N/A <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 El Facility Contact 0 Property Owner Cl Contractor 0 Architect <br />pAybietv 430,,,t4e s r <br />"NteEiVerti <br />la <br />42.8 1 8 2 <br />First Name Last name If contractor, indicate type <br />Address City State <br />Phone Phone Email 8AN <br />L..... <br />025 <br />JOAO,/ RA, <br />1..... -.7vmeivr <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all sPhififi1r41, ect <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on <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 />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 />0 New Facility Si 'Existing Facility! <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />1./(. K 0,- N •1 ba.c\-\\ 3i3-- <br />Site Address <br />5CD -1 v\I hceor\ont 5 k .t. <br />City <br />S -1-0 C K ci-Y\ <br />State <br />C A <br />ZIP <br />q5 .03 <br />APN <br />137 - 14 - I a <br />Supervisor District su.; te 13 i <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />El Consultation '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 />Accepted By <br />-- Q. <br />Assigned To Linked FA ID <br />Date , <br />PE <br />Fee <br />s Fl <br />Record Number 5R.a500255 <br />)(Cash 0 Check # 0 Confirmation # <br />Payment <br />Received By <br /> <br />1 <br /> <br />Rev 07/10/2024 '520531-MS1