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New Facility [5 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Supervisor District <br />[3 Repairs or Remodel Consultation Change of Owner Other <br />License Plate Number <br />S Facility Owner Billing Party 0 Architect Facility Contact Property Owner Contractor <br />EkBilling Party Facility Owner Facility Contact Property Owner Contractor <br />City State ZIPID 83703Boise <br />Phone <br />com <br />13 Facility Owner Billing Party Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberLast name <br />City State ZIPIDBoise 83704 <br />Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />If contractor, indicate type andFirst Name Last name <br />Address City State <br />EmailPhonePhone <br /> OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Assigned ToAccepted By <br />Fee <br /> Check it <br />Rev 07/10/2024 ?(?o9%rio <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 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 />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />Email <br />dawn C@psaich, <br />ZIP95304 <br />Type of Service <br />Requested <br />Comments Plan Review for T.I. to replace cases and related equipment in the Service Deli and Seafood Dept. <br />vin <br />Mother authorized agent Architect <br />Title <br />^^y\rchitect <br />If contractor, indicate type and license number <br />^^Confirmation # <br />C (f O <br />PE <br />I_/A <br />f 3 tn* <br />Petersen Staggs Architects - Dawn <br />Address <br />5200 W State Street <br />Phc2083451462 <br />stat^A <br />First Name <br />WinCo Foods, LLC <br />Ad(D?6S N Armstrong Place <br />Phone <br />2083770110 <br />"TaTcfwell <br />Date7-3-^5~ <br /> Cash <br />Facility Name <br />WinCo Food Store #103 <br />SltP^djgsPaviiion Parkway <br />APN <br /> Architect <br />__________ Jv <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that aIITsTfc*!rt^J***- <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <—i - ' - . SpntPmher 3 7(P5 <br />APPLICANT'S SIGNATURE: ---- ----------------- DATE: ^ePl(“1IIDel -J, <br />Linked FA ID <br />r9O2-C7gg^ <br />Record Number . <br />Payment , <br />Received B\L>y/ (/ <br />Cltv Tracy