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0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />'Bar be cue. 1\1 ci...-i on <br />Site Address <br />15 338 s. I-1 at- I cui Rd. City <br />La..+hrop <br />State CA ZIP <br />q 5 330 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation EZhange 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 />Melling Party leracility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />McA ro i If contractor, indicate type and license number <br />) 2 77 P;soi Co-Lae --S--Lokt13i, C. 6 1111? S : 0 <br />07 660162! <br />hone 111111)yeir flehr1/ 0 e I 0 jri-tai L: (0 01 <br />vow <br />0 Billing Party 0 Facility Owner Vra-cility Contact 0 Property Owner 0 Contractor 0 Architect <br />L--47 rn <br />If contractor, indicate type and license number <br />,Q3 '7 7 PLSC/ Co-Lcie .-/uckfort EIN9.S-- b ‘ <br />gal t-15-0.2,;21 <br />Phone 1111110 v-e_e mei, ,00i 0 0 rrk• - ' 63 "I ' <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: I, the <br />specific ENVIRONMENTAL HEALTH DEPARTMENT <br />form. <br />I also certify that I have prepared thik <br />Standards, STATE and FEDERAL laws. <br />undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />i/— 0 I <br />0 PROPERTY / BUSINESS OWNER <br />If APPLICANT is not the BILLING PARTY, <br />AUTHORIZATION TO RELEASE INFORMATION: <br />release of any and all results, geotechnical <br />DEPARTMENT as soon as it is available <br />0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />proof of authorization to sign is required <br />When applicable, I, the owner or operator of the property located <br />data and/or environmental/site assessment information to the SAN <br />and at the same time it is provided to me or my representative. <br />TOCA7T <br />Title <br />4141 <br />at the above site addre <br />JOAQUIN COUNTY ENVIRO <br />e4,1‘ <br />IV a / 1 <br />410horize t4rep <br />00,04v <br />a_*.k <br />Accepted By <br />S. Ba[1.kf GocIr <br />Assigned To . i K , LI 11 hare 5 Linked FA ID <br />FAM <br />'ort, <br />,Q g 4 akr <br />Date <br />1.31. a5 <br />E iCo0 a Fee 5i-4-a Record Number <br />0 Cash 0 Check # al/Confirmation # /q32719/1/19....i//q32719/1/19....i Payment <br />Received By Wilir <br />Rev 07/10/2024 <br /> pizosSetlit+