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❑ New Facility Existing Facility <br /> „ YLC Q�A <br /> San Joaquin County Environmental Health Department J <br /> Application Form <br /> M <br /> Na e <br /> Of4-(cle'(2)mM Mof CLI " <br /> Size Address UwLk 14101 <br /> S#ate 6 ZIP S 2/, <br /> APN 33 Supervisor District fV V <br /> Type of Service ❑Application for 1�� <br /> nsultation ❑Change of Owner ElRepairs or Remodel El Other <br /> Requested Operating Permit � ,� <br /> Comments ��T /1 �j� C v�►/► ^ <br /> l a K�fL ! w� r — • 1 <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 /> Willing Part cility Owner Facility Contact ElProperty Owner ❑Contractor El Architect <br /> �Llb ti A6 30)�T <br /> First 10 <br /> Last na V C If contractor,indicate type and license number <br /> 4ddJs Vv ( C 4' l.z��� mate/ SIP "l �20 <br /> 0 2 &q� P,¢one Email (/ <br /> vq 5 4,morc4l 5 Q ex w� <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type anPc YM,ber <br /> NT <br /> Address City State CE1VEt) <br /> Phone Phone Email SEP 0 3 202 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor COUNTY <br /> RONMEu NT <br /> First Name Last name If contractor,indicate type an ENT <br /> Address City State ZI P <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned propertyorj7usiness owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPART 4hat <br /> es 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 thi Ica' work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL la /f�/ /�� <br /> Q APPLICANT'S SIGNATURE: DATE: C '(` <br /> PROPERTY/BUSINESS OWNER ❑OPERATOR/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 tome or my represe ive. <br /> Accept B G {� Assigned To Linked FA ID � <br /> Date PE Fee c 0 R ord Number <br /> �'3 2 13 / '�`� 22scal��� <br /> Pa ment <br /> ]I❑Cash I Check# (�3 El Confirmation# Received By <br /> Rev 07/10/2024 �1 <br />