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r ❑ New Facility 9KExisting Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name ;� <br /> /i7hn Orme PIjql I <br /> n <br /> Site Address City State ZIP <br /> ;79-,S 111160V"RD .4VE VZ11 A/ Cl+ 9S,ZJS <br /> APN Supervisor District <br /> l7 SSrs/z <br /> Type of Service ❑Application for ;k nsultation ❑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 ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> filling Party ❑Facility Owner EIFacility Contact ❑Property Owner Contractor ❑Architect <br /> First Name Last name If contractor,indicate type nd license number <br /> �i9•� �x DRrt-LEW2 (C-Gs 3-I3i11 <br /> Address l 90/ me C01VIR�& f7. C'ty State ZIP <br /> r/ J�� ,�C�t nweIrto CA- 9sp;L8 <br /> P}-4.one Tone Email <br /> (Q16�38 3 -21 S�fiVe @4,K 1001W /nC• coin <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br /> form. <br /> I also certify that I have prepared this application an a;thork to be performed will be done in accordance wit all SAN J[AQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. .Z y <br /> APPLICANT'S SIGNATURE: / DATE: ✓ <br /> lM PROPERTY/BUSINESS OWNER ❑O R/MANAGER ❑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,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 L Linked FA ID <br /> Date PE qq Fee Record Num r _ <br /> L `t �..� JAL _" ✓�- vt <br /> Payment <br /> ❑Cash heck# 1 rJ ❑Confirmation# Received By <br /> Rev 07/10/2024 <br />