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N' New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name ii <br />Ylo\.ko, &IctcYahk. <br />Site Address " <br />S \ 11L-4 N • PI 110 icA M , <br />City Staten L <br />VA <br />ZIP <br />61152.63 <br />APN S ervisor District <br />Uji kr <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 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 />/killing Party )iFacility Owner (BCFacility Contact 0 Property Owner 0 Contractor 0 Architect <br />First4.arne <br />Yak., A 144 It ir <br />Last ner9e i <br />1.)101 \ Ler <br />If contractor, indicate type and license number <br />Address <br />1 1 45 1.-,. ktaqvicA icA <br />e_.5i1,y State ZIP_ <br />, rid,„ <br />DI . tea P <br />hone j 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 />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 />APPLICANT'S SIGNATURE: <br />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 />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 />is p lic tion an t at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />I <br />DATE: O'l 2 q 2024 - <br />OWNER \4OPERATOR / 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 />, <br />I'VeCt.1 <br />*ft/ Title <br />OC T i 4 at the above site address, heresy authorize e <br />JOAQUIN COUNTY ENVIRONMEN 1irzi.ettie1JIN cc <br />Thoz4vra <br />Accepted B/1.1.—\ Assigned To <br />'(—r-t k—e----- <br />Linked FA ID <br />Date <br />t O t '2A / <br />PE <br />i IP° <br />Fee . , <br />Ii:iti. . GU wt.).7-4 6( bc9._-. . ftecord Number Inv- i(q?, <br />eivr <br />Vetp <br />Ivry <br />Rev 06/12/2024 <br />P122q)01 <br />IC) 91-1 a LPM