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. • San Joaquin County Environmental Application New Facility 0 Existing Facility Health Department Form Facility Name LIV M M. Gi.avieS k k.2 FSCA V Site Address City State cil- ZIP c I r7 q I APN Supervisor District Type of Service Requested 94 Application for Operating Permit 0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other Comments , i h i S .1 S CD'il cictj culfuNecci ev.c.v.i— in ce.-4)--c._. p 0 fic_ ,ato a A.,frt iv, 14 If mobile food truck or pumper truck License Plate Number VIN Contact Types required ,Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect 121 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name SCCCIA;)1 Last yr K.Olecit If contractor, indicate type and license number Address . & I /4 5 . Ce t,f-y-r-A Pc,,k oc-/ City NO 411.,4-n in You,se State (A ZIP q I-7 q I Phone 610 -61- VI/ Phone Email o Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email BILLING ACKNOWLEDGEMENT: specific ENVIRONMENTAL form. I also certify that I have prepared Standards, STATE and FEDERAL APPLICANT'S SIGNATURE: TA,PROPERTY / BUSINESS If APPLICANT is not the BILLING AUTHORIZATION TO RELEASE release of any and all results, DEPARTMENT as soon as it I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, laws. S rs C)n I r1 V (1 VA e DATE: GE11 2—] 9 1/ OWNER 0 OPERATOR / MANAGER MOTHER AUTHORIZED AGENT PARTY, proof of authorization to sign is required INFORMATION: When applicable, I, the owner or operator of the property located geotechnical data and/or environmental/site assessment information to the SAN is available and at the same time it is provided to me or my representative. —fre a J Li VP/ C k./' Mr" f Title at the above site address, hereby authorize the JOAQUIN COUNTY ENVIRONMENTAL HEALTH Accepted By \ f"\ \r\ C\ ( .f.'s Assigned To i __., \ 1"\ \C\ ov( e,, Linked FA ID .FA 64:36 I +2:7 _ Date 9-) • I 2— - 2—LA PE • \ \C)C1 Fee \ 1- 2_ — Record Num e I A PZ 0 Cash 0 Check # 0 Confirmation # ‘ , x 5'2A° 3b to st Received By Payment Rev 07/10/2024