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New Facility <br />San Joaquin County Environmental Health Department <br />I FkiMv Ninx <br />C/4 <br />$uprrv>io> Dntlifl <br />O fMlllty Owner <br />requrwl <br /> Architect Conlrxlor(J Property Owner facility Owner Facility Conuct <br />I if contractor. indicate type and licence numbe- <br />tmail <br /> Architect Property Owner facility Owner Billing Party <br />If contractor, eidicate type and licenve numberfirst Name <br />1 Addreu <br /> Architect Contractor Property OwnerO Facility Owner Billing Party <br />last nameF irM Name <br />ZIPAddress <br />f mailPhonePhone <br />DATf <br />Accepted By <br />3 IVa . C&(2> <br /> Check* <br />Re. O7/»O/X»4 <br />POdWliz; <br />\ar} <br /> Other Application for <br />Operating Permit <br />G^\^< <br /><ist>ng Facility <br />/ bu i y 72- dtj/TUH <br />acility Contact Property Owner <br />£^r.iV^_ <br />Phone Phone (mail <br />__________ <br />■kjv | license Plate Number <br />------------*-Sde Address <br />APN <br />. ^10 ~ 5/ UrO <br />1 I ype o< Service <br />Reouested <br />Comment' <br />Lwu 1£ <br />, II mobile food tn <br />pumper truck <br />RECBveo <br />15 !ls <br />zip7533Z/- <br />95'33^ <br />First Name ' <br />Application Form <br />S Tips <br />BuH-on /Ivc <br />tystri'c/ 5- RobeH- <br />(TConsultation I Change of Owner [O Repairs O' Remodel <br />RccervcdBy <br />“WK□ Cash ' <br />n'ian^c^'\>u,f <br />last nim»^ . <br />f^rJVL <br />< > ■' Phone (mail > • <br />City <br /> rBtlllNG ACnNOWlttXStMfNT I. the undersigned property O' business owner, operator or authorised agent of same acknowledge that ail Site and/or project <br />specific (NVIRONMlNTAi MlAITH 01 PARTMf NT hourly charges associated with thrs project or actnnty wilt be billed to me or my business as identified on this <br />'also certify that I have prepared this appj<ation and t'^rffir work to (^performed w.U be done « accordance with aU SAN JOAQUIN COllNrr Ordinance Codes. <br />_3kh^ <br />□ PROPtRTr / BUSINISS OWNtP □ OPt RATOR / MANAGIH Q^HHIR AUTHORlZlO AGlNf Church Cornu! I <br />It APPllCANT is not the BllUNGPARrr, prod of authorisation to sign is required OS fTt f\\ (jO/\LLT3 <br />AUTHORIZATION TO Rill AM INFORMATION When appUaMe, I. the owner or operator of the property kxat.-.Cal the above hr address, hereby authorise the <br />, release of any and all results, geotechnical data and/or envitonmental/sile assessment mformatron to the SAN KJAQUIN COUNIT (NVIRONMlNTAi H(AlTH <br />| DfPARf MINT as soon as it is available and at the same time it is provided to me or my representative. <br />If contractor, indicate type and license number <br />___ <br />State <br />last rjAine <br />/3r'4./4'rl<U/«____ <br />______ <br />brzi/£spainh'nj <br />O facility Contact <br />Z com <br /> Contractor