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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name _ <br /> rCA se-to ,!bPK1 7- <br /> Site Address City State ZIP <br /> G8 o S. (cam,,-,IeaL A v Lo DI <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation P&Change of Owner C]Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VhN <br /> pumper truck I E <br /> Contact Types ❑Billing Party ❑Facility Owner ®Facility Contact 19 Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> frst Nam#W If contractor,indicate type and license number <br /> 1` 4AII S�nf y <br /> ow <br /> P M�tRsN CR K C-� 8�o��lrcc� rid <br /> 'Ph—.n—, r: <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 0 e ❑Architect <br /> First Name Last name If co�nVoi`li,Njdic 7peand license number <br /> Address City State 3Op'wJ% Alg ZIP <br /> p� pNMsN'� <br /> Phone Phone Email �LtH Q <br /> H <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 apKi cationanl that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards DERAL laws. <br /> ItPROPERTY/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 representative. <br /> Accepted By Assigned To Linked FA ID <br /> e rlY C - /-Cp r CA S C-D 12— FA Om Z 5 281 <br /> Date PE 7 3 Fee$ �, ca Record Number <br /> SR.2CSQ)ll q2- <br /> Payment <br /> Cash ❑Check it ❑Confirmation n Received By <br /> Rev 07/10/2024 <br />