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0 Facility Owner <br /> Application Form <br />8,, C„, <br />Roost Px.x.0 <br />o New Facility . <br />'tx Existing Facility <br />San Joaquin County Environmental Health Department <br />Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation <br />Comments <br />if mobile food truck or License Plate Number <br />pumper truck <br />Contact Types <br />required _ <br />0 Billing Party )4 Facility Owner <br />First Name <br />3nvyee--1-- <br />Address 91. 4/110ekvz <br />Phone Phone Email <br />0 Facility Contact <br />Last name <br />CIY-1 <br />0 Property Owner <br />Z11,1 <br />VIN <br />_ <br />Facility Owner 0 cility Contact 0 -Property Owner 0 Contractor TO Architect <br />et <br />City <br />-1 j-vi . <br />0 Contractor 0 Architect <br />If contractor, indicate type and license number <br />Last name <br />State <br />Email <br />ek.he r\ e-e4 S <br />0 Contractor I o Architect <br />Last name <br />0 Billing Party <br />First Name <br />Address <br />Phone <br />El Billing Party <br />First Name <br />Phone <br />0 Facility Contact 0 Property Ovmer <br />0 Facility Contact 0 Property Owner <br />If contractor, indicate type ali <br />City State <br />Phone <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 Co es, <br />APPLICANT'S SIGNATURE: k(ci viol n ota e- DATE: Standards, STATE and FEDERAL laws. V'') <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title 07 <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 />\ ZIP <br />E8 1 IV <br />SA NjoAQ u 2025 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowleeke <br />ItiR0, • <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my bum <br /> t DiLTAITY <br />form. <br />TMEr. <br />C.) -2---- ol--),s-- <br />Address <br />Phone <br />Accepted By <br />U ." <br /> <br />tc.,, \\(--N. cs...1--e S <br />Date T-PE <br />2-0-A.-2--R I: \ \oc)-2... ....) , <br />0 c,sh, 0 Check # <br />Rev 07/10/2024 <br />Record Number <br />S0-25 VbB52- <br />Payment <br />Confirmation ii c\ <br />200 <br />Received BY <br />0 Facility Owner <br />Facility Name <br />Site Address <br />If contractor, indicate type and license number