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I=1 New Facility ;41 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />, Facility Name <br />ID i 22 f\ Ni K Pk 45 D -C°/)"" <br />Site Address 4-9 5 0 RACIF-1.1 C Aktc <br />' 3 V 3 <br />State i f \ ZIP City 51-6 c A) <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation p 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 />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name .1 Last name <br />CALi)—{Niict ri-ii-iNk NI )‹.-.5 fil\i c <br />If contractor, indicate type and license number <br />Address 4. <br /> 9c--) y fAc , 1-7;c M't -*-30 <br />City ,..__ <br />‘.) 0 ( --1-.--,,i <br />State <br />c c. <br />ZIP <br />q 52 o7 <br />Phor19)x A <br /> °O2--,:_, <br />Phone <br />\ <br />Email <br />c PA-P-7 )9)°1 6 Ah00 -(4)(Vv` <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 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: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />0 PROPERTY / BUSINESS <br />If APPLICANT is not the BILLING <br />AUTHORIZATION TO RELEASE <br />release of any and all results, <br />DEPARTMENT as soon as it <br />APPLICANT'S SIGNATURE: <br />I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />this application and that tiT work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />laws.cm <br />DATE: 4-j9 i 2._ -2- 5 <br />OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />PARTY, proof of authorization to sign is required <br />INFORMATION: When applicable, I, the owner or operator of the property located <br />geotechnical data and/or environmental/site assessment information to the SAN <br />is available and at the same time it is provided to me or my representative. <br />Title A Yilf ri.. Jo <br />CA/7' <br />at the above site address, 14... ette <br />JOAQUIN COUNTY ENVIROINENTAL H alb <br />'Iri? 2 <br />Linked FA ID "IN jo 5 <br />Accepted By <br />, D-e_Cc C. <br />Assigned To <br />Lkiclici, B. AQ FAcbql Bo Aftlp?,,,.(1/Nce-„, <br />vIyA, •-•Litipr,, _ <br />Date , PE Fee <br />c <br />Record Numbert--1----- S25(2)19RO <br /> <br />0 Cash N(Check # <br />t\ CO t <br />0 Confirmation # <br />Payment <br />Received <br />Rev 07/10/2024 <br /> <br />112052(41,1