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San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name PIWT )n 1 n l � Dc'SiteAddres248 W Fremont Street city Stockton 19✓J State CA ZIP 95203 <br /> APN Supervisor District <br /> Type of Service Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party acility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Janeen Last name Taplin If contractor,indicate type and license number <br /> Address 737 W Montecito Avenue city State CA ZIP 95391 <br /> Mountain House <br /> Prh�T5 640-2617 Phone Email <br /> \v � janeen@pineapplewhips.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner I-]Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and JLe r <br /> / <br /> Address City State ZIP I,A <br /> 6 <br /> Phone Phone Email v r <br /> Sq J ?O? <br /> 1ySX / / <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that I tejT <br /> Ty <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as iden if(� <br /> form. T <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 Codes, <br /> Standards,STATE and FEDERAL laws. r— 2/25125 <br /> APPLICANT'S SIGNATURE: 9 ^f DATE: <br /> XPROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <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 /> Accepted By ) ) r ct CAI Assigned To Linked FA ID <br /> Date PE l Jl O Fee <br /> em �in �m '� 2 J Ste/ <br /> c � <br />