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0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />ce.tkesq ty-) u-cLos <br />Site Address , <br />VW N El Dorado kreei't <br />City <br />Stoc,<Li-on <br />State <br />CA <br />ZIP <br />c15,002 <br />APN Supervisor District <br />Type of Service <br />Requested <br />YApplication 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 />—a Billing Party CI Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor CI Architect <br />First Name <br />V•cit he,1 an Extm-414-tiv -c• Last name <br />itryii90 -- carnari 110 <br />If contractor, indicate type and license number <br />Address <br />)-1 LI GI P%pre,nas Aq,"A e <br />City <br />.9i-v4-on <br />State <br />GA <br />ZIP <br />96110 <br />Phone <br />(510359 - 33-23 <br />Phone Email <br />-tuosv ovidowl9corct I.com <br />CI 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 CI Facility Contact 0 Property Owner 0 Contractor CI 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 FEDE <br />APPLICANT'S SIGNATURE: <br />RKROPERTY / 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 />this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />L laws. <br />CEL4.--•-' DATE: 'r\ c2- <br />OWNER 0 OPERATOR / MANAGER CI 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 />!A YME. <br />Title ITE*Ce it <br />at the above site address, herebFifigorizeothe <br />JOAQUIN COUNTY ENVIRON <br />7..TAL <br /> HEAL4 FO 20 <br />— Jain, r Aft - %WI ha. _ <br />Accepted BylAi0.0 j Assigned Totiiix.• raixikaz_ •••eumiozoww,,,v-rry Linked FA ID kom-Lem <br />Date 4 (24-----;: Fee Number ,riegrcc1 \ (0 5 5 <br />0 Cash 0 Check # Eel/Confirmation # 19u s(s-ze Payment 0-775 <br />Received By <br />Rev 07/10/2024 <br /> <br />PROSL13251-