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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />I ono's <br />Site Address <br />LA <br />APN <br />GJ Change of Owner Consultation Repairs or Remodel Other <br />VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />□’’Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />ZIPState <br />Email <br />□’Facility Owner □’Facility Contact Billing Party Property Owner Contractor Architect <br />Last name If contractor, indicate type and license number <br />State ZIP <br />Email <br /> Contractor Architect Property Owner Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPAddressCityState <br />Phone Phone Email <br />DATE: _ <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER <br />Title <br />Linked FA IDAssigned ToAccepted By LBSB <br />PE $1^9.I (p02 <br /> Cash Check H <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Last name <br />ZIP <br />9 5^07 <br />75407 <br />“'''AbFoofjiofcf’oMrroh G <br />Contact Types <br />required <br />/______ <br /> Billing Party <br />Type of Service <br />Requested <br />Comments <br />U Ly\ <br />Phone <br /> Application for <br />Operating Permit <br />5+ore ^0^^75 56^ <br />License Plate Number <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. p. X" ' <br />I also certify that I have prepared this application and that the work <br />Standards, STATE and FEDERAL laws.—— <br />APPLICANT'S SIGNATURE: _____________:L. ~ T <br />□'PROPERTY / BUSINESS OWNER <br />State <br />__CA <br />Phone <br />City <br />be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />04/10 <br />Firs,Name AsH|S>^ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required APP //) In <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby JuWor^^' <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENViSaKf^r^AL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Record Number <br />3R25<20q<?3 <br />PATBL <br />°ale4'IO-75 <br />Confirmation « ^5 <br />AddreiS’(43S FJ MovcL L^y <br />Phone <br />K). LAq/dh <br />Supervisor District