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❑ New FacHIty XFx sting Fad IIty <br /> (needs50) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Frei ft Name <br /> SImAddrete City k State � tP'`L <br /> t 14 <br /> APN superwitnr owridt <br /> Type of sworn d Apptlot Ion for Cl Coassu i tloo Q Cltartige of OwaSer lVepabrs or Itemo.del U other <br /> "utmed CperatingPermit <br /> Commrrrt9 <br /> If m4b1lefood truck or License place Nu mbar YIN <br /> pumper buck <br /> CAnlatxlYprrt IE9AlingParip 0FatiEityowner 0Frc011tyCoMaa QPropertyCtwner 0conlractor IE REgwntar <br /> requrred <br /> Bl�lr3 Pao#y Qf tiltyOwvr ❑FargllyCantart ❑Property Owner C r QAFI: Ed <br /> Flrse Name , � Last n� � ���� If contrarmrr Indira typefnd ilYcernse nurtlht•r <br /> t iiQJ ICES <br /> Address l; y � Scat A �I <br /> Phone �yy Pfwoc Emalry LtU <br /> Q Ming p'Ay ❑Facillty 0wrwr ❑Faulty CantQct 13 prape ny Owner ZI Contractor 0 ufchltedt <br /> Firstbiime Eastnprme IfcDaLF torrIndbcatetypp.3hdrlCensenumber <br /> Address CRY $#ate 214' <br /> Phone Phone Emall <br /> 0 Ulkng Pi rty L]Facalliy Owner d Faollty Contact a Pr0;4!rtp owner D Contractor 0 Aej-h9tPVAYJW <br /> rlf%l w2Fne I-ml name II cantrimor,Indwiktetype end li€eni <br /> Addnms [.fly State L•iF } <br /> L <br /> Phone Phone EmaII AQU#� U <br /> Nry <br /> BILLING Ad R(YWLIDUEMEM.Ir the a nder4*ed property or buslness OlYner,aperitar hr au;harized agent of tame,acknowledge that all sitete and{or� <br /> speslfir ENVIRONMENFALHEAIT}t DEPARTMENT hourly charges associated with this project ora❑IMI1V w911x b0led to Me Or my huffiness asldaatefled on this <br /> fOFIR. <br /> I olio rertlfy That I asaue prepared this appl Jan nd that the work to he performed wIE be done In accorcKanCe With 3H BAN JOAQUIN CouNnOrdlrarmCodet% <br /> 5tanderds,STATE and FFOERAL I 1 2-6APPUCANr$SiQNATURE; DATE, +4 I <br /> 0PItOPfR1YfB{151HExx13wHER 13OPFRh70tlfM9hNAGEFt ATHER AUTHOR=AGErfr <br /> 1F APPIJCAI'!'T is not She ACLLINI•,PARTY,Proof o}aWlhorixpllpn to sign is requlmd <br /> AIJ7Ha ZATKW Yo RELEASE INFOWAY14N:When 6ppfkabtr,a,the omew or operator a the pro;l"Jocaled at the akmft site address,hereby autharkm the <br /> release of any and all resuCtf,geotechnk3W data and/or Emckonmental/sYte assessment I arrna#on%the SM JOAQLIIN C4IJNTY ENVIRONMENTAL FiCALTH <br /> DEPARTMENT as span as It isavaltabreand at The same lime IR h prCN1cItd to me or my WremtaiM. <br /> Accepted ✓ Y-4silipedTo LIn1oed Fit ID <br /> Date I f , W Fe Record�bff <br /> *501 'i 2 <br /> e <br /> 4 cash ❑Che�c A Enfi—::tlan k Paymnt <br /> { Payrn m BY <br /> Rev 10'111ol202a ?.of$ <br />