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Phone Phone <br />0 Billing Party <br /> 0 Facility Owner <br />First Name <br />Address <br />Phone Phone <br />0 Billing Party <br /> 0 Facility Owner <br />cDAL- pe(iN \\QB , <br />V\-ec‘ SQ pgr <br />0,\A(010, <br />Cry.\ <br />First Name <br />Address <br />New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />AoDlication Form _ _ <br />Facility Name s txka ‘1 Sweet- <br />Site Address 1 (Z0- -7-a. hoe Circ., le City _rico cli State ZIP cts 37 6 <br />APN Supervisor District <br />Type of Service <br />Requested <br />t&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 trud< <br />license Plate Number VIN <br />Contact Types <br />required <br />isi Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />$ Billing Party x Facility Owner piCFacility Contact x.Property Owner 0 Contractor 0 Architect <br />First Name A Last fruA)(oca name <br />5 U. ha‘( If contractor, indicate type and license number <br />Address <br />t (> <br /> 2,0 - Fa he ci cc) e City Traul State CA ZIP <br />Phone 025)q80-76V7 Phone EmailC4U, rpm , . <br />SvAeta4T9rncid•coni <br />BIWNG ACKNOWLEDGEMENT: I, the undersigned p <br />specific ENVIRONMENTAL HEALTH DEPARTMENT ho <br />form. <br />I also certify that I have prepared this appli bon an. <br />Standards. STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />sil i%.c fUll ail •...,..P.J111 I VI UllIctIlLe <br />DATE: 9lio 7-41 <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGEIr 0 OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BIWNG 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. Assigned To linked FA ID <br />Date <br />'C\ • 1 \o2\ <br />PE <br />\\00 (2) <br />Fee <br />1 B b — <br />Record Number <br />9F)240i0 L1-2- <br />\ S 9 bg 2_ Payment <br />Received By 0 Cash 0 Check # Conflrmation # ?_)1)) <br />Title <br />YR21-iM2D <br />Rev 07/10/2024