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t• <br /> New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name S LANIn, I SVJe �ptJ Site Address /°�(� 1 Q I_co'e �. city TV- State 7•-/I zip <br /> q-S-37 <br /> APN Supervisor District <br /> , v C.�"'� <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 IX Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party Facility Owner Facility Contact ).Property Owner ❑Contractor ❑Architect <br /> First Name p Last name rtt ha\( If contractor,indicate type and license number <br /> ry �a V <br /> Address [r_ :w Tahoe Cr cG�� city 170E State C-A ZIP <br /> Phone 1(� V IP/hoone'1 1 EmalICALl,roM. <br /> g2S)g8D-Vz� S�lna�t rna�l• M <br /> ❑Billing Party ❑Facility Owner d\ �^ ^ e `Y \ <br /> First Name <br /> Address <br /> Phone Phone <br /> ❑Billing Party ❑Facility Owner <br /> First Name c <br /> Address <br /> Phone Phone <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned p <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT ho <br /> form. <br /> I also certify that I have prepared this appli lion an_ __ r-.�,•..��^„ �_�� _ a=w��'_�^'" "'^""^`�""`" """""""""C a uuCs, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANTS SIGNATURE: DATE' <br /> PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGEFV ❑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,1,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 Assigned To Linked FA ID <br /> L. r\\-\0"/c� L_� -\�-No.reS <br /> Fee Record Number i rn Date PE Z4 0 q Z <br /> $,a 2G Q� Payment <br /> ❑Cash ❑Check q �Conflrmatlon 4 1 �J I v L Received By <br /> Rev 07/10/2024 2 <br />