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A New Facility 0 Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name 72\41 1-)1.--1- $ r t 1 Site Address n o '3 Pral \ \ --e) CO tek I l • . ••••••• ...‘ ...1. , City • StC5e_i*In State MI- ZIP 9 Voir:3 APN Supervisor listrict Type of Service Requested AApplication for Operating Permit 0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other Comments r.),e,,,c, Iv1F*F Cory:,-,;,.1k.c,chox\ (Sc,csck.ff-Ne_ry\-o C\XY/I) If mobile food truck or pumper truck License Plats Number S CY1 05 V\I i VIN 1 .1)'11.V3 ricill Contact Types required 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect di Billing Party Facility Owner V Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name . LA name 1 If contractor, indicate type and license number Address 27-1.L.11.-- Sr)je_e--) iZcX C'ty curk State - ZIP 1 -z_t0 Phone Phone apci 5‘ 3 -90 bc2, Email --zyn CC) ID Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner El 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 El Facility Contact 0 Property Owner El Contractor El 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 FEDERALjarg APPLICANT'S SIGNATURc Cl 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 nd t the ork to be performed will be done in accordance vith all AN JOAQUIN COUNTY Ordinance Codes, c...X.e.ed ... DATE: Li Ci 2-5 PA yill OWNER 0 OPE OR / MANAGER El OTHER 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. R ece ENT /veto Title APR 0 0 at the above siluldress, hereYy 2025ize the JOAQUIN COUNTY Et. # 't io Isi-4,...HEALTH HS-At T AhtIZVJAITY AL Accepted By 3eA2 e C Assigned To t...,.c.1c). cb, Linked FA ID -..ri- r &TNT Date PE kic(t3 Fee \-2.00-I 19._. 0') Record Number 72)-pzsof BA -3 *ash 0 Check # 0 Confirmation # Payment Received By CiL Rev 07/10/2024 PR2500310