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t9i New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Si- i \/Ca ON --.0()cl, s <br />Site Address <br />APN Supervisor District <br />2.6l(l) RoD Gfande -4 <br />City State ZIP <br />Type of Service <br />Requested <br />Vt Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />TQD,A) Class A CFO <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 />W Billing Party 0 Facility Owner tgl, Facility Contact 0 Proper y Owner 0 Contractor 0 Architect <br />First Name ., <br />D‘v,#), <br />Last name <br />tV\COVe6CC <br />If contractor, indicate type and license number <br />Address <br />-Z51C, R .,,0 eivondt Dc <br />City <br />l a Clj <br />State <br />Lk <br />ZIP ( (.-33 1- --4- <br />Phone <br />(5 i T Y 31- \ - a0 (f.,4 <br />Phone Email <br />a WUCk• Moliveckli Namok. corn <br />0 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 <br />CO'ke-._ -4- Phone Phone Email .---\-\ pe( 0,--,- <br />_ _ 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property \ ?_) . CA • ( • 2 <br />- <br />First Name Last name <br />Address City <br /> <br />- _ <br />Phone Phone Email <br />\ '‘Si ., .e__K\Al•-1 4c) - _ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly <br />form. <br />I also certify that I have prepared this application and <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />or business owner, operator or au <br />charges associated with this project a <br />that the work to be performed will be dc <br />ck: 1 • ,. . <br />s ,f-Nc\C1‘ \ \ • C (V\ <br />0 PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTHER AUTHC <br />If APPLICANT is not the BILLING PARTY, proof of authorization <br />AUTHORIZATION TO RELEASE INFORMATION: When <br />release of any and all results, geotechnical data and/or <br />DEPARTMENT as soon as it is available and at the same <br />Title <br />to sign is required <br />applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />time it is provided to me or my representative. <br />Accepted By <br />LA)ci,tA V). <br />Assigned Tp <br />Ko,cle,(1)e L <br />Linked FA ID <br />Date <br />id 211 zt-i- <br />PE <br />I(V,E) <br />Fee <br />(1,i e, . G'T <br />Record Number <br />t)p2ittirrz --1- 010 IL, <br />0 Cash 0 Check # , 0 Confirmation # <br />Payment <br />Received By <br />Rev 07/10/2024 <br />VIZ 0o315