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Phone <br />0 Billing Party <br />First Name <br />Address <br />0 Architect <br />type and license nu <br />ZIP <br />that all site and/or project <br />siness as identified on this <br />0 Check # Confirmation # 10 <br />Fee 4Z(0 <br />Record Number j. 4 6 ii24.7 <br />Payment <br />Received By <br />Date g * lq • <br />0 Cash <br />[iffNew Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />I._ iro <br />Site Address <br />I CI 1 4) Ha-Rlook SV <br />City <br />1.4poi,Mtn itiiSe State <br />Cli <br />ZIP <br />gS3c1 i <br />APN Supervisor District <br />Type of Service <br />Requested <br />4plication for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments r, /--_- <br />k—' 1--- c, k6tC,D(' -}1 niltkkl K1C‘', i <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />, <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />INKilling Party MeKcility Owner [7eKcility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />Lv cal <br />Last maze , If contractor, indicate type and license number <br />Address Address <br />I LI I ?) S ' N a4t0a a . <br />City <br />KIAlkdO haf:.•12- <br />State CX)1 Z I PCA 5SC1 I <br />Phone <br />015)c icS-R3S 1 Phone Email <br />k v\etiSeo:AestK @ .• Tiok\ coAri <br />0 Billing Party — <br />\ eos- yl(c_ess e ,i_) C \--"= , <br />ef ,----\- -Q\ \0 <br />\ ^ t , . <br />0 Architect <br />type and license number First Name <br />ZIP Address <br />Phone <br />BILLING ACKNOWLEI <br />specific ENVIRONMEI <br />form. <br />(-\ coo • Q_ 3 er\o...; . <br />) <br />L-- <br />I also certify that I have prepared this ap ication and that the work to be performed will be done in accordance all SAN JOAQUIN COUNTY Ordinance Codes, <br />L- <br />Standards, STATE and FEDERAL laws. / :11.34L. !(--) <br />dc'"-- DATE: q Va i .2., I APPLICANT'S SIGNATURE: At i-i K c)I'4 PA <br />NI/PROPERTY / BUSINESS OWNER l!ri<144014,TOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />ii'ic ill atir 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'ti athori4e die <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONM406,4EALTH 4124 <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. FA/WI QUitti <br />tik,4 RoN ' Cu, , 0'0 1/6 `47-y <br />Assigned To !, <br />1-- 1?(.1}-/ a rlii) <br /> Linked F ID <br />ce) i <br />DFP Ar rilt <br />rvi6Apt <br />Accepted By sp) <br />Rev 07/10/2024 / <br />..tv•A A c c eQ c.tAAA-tk-tn- (D O t)