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9 <br />New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Site Address <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />OProperty OwnerBilling Party □ Facility Contact O Contractor(^Facility Owner □ Architect <br />If contractor, indicate type and license numberLast name <br />Phone <br />□ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner Facility Contact <br />If contractor, indicate type and license number <br />□ Architect□ Contractor□ Facility Owner □ Facility Contact □ Property Owner□ Billing Party <br />Last nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br />ilication am work toit tlIs 3| <br />□ OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER <br />Assigned ToAccepted By Vidal Pedraza Francisco Ruiz <br />pe 1602 Fee 179^te 8/6/2025 <br />□ Check#□ Cash <br />KPa50252Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />State <br />--- <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 environrnental/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 to me or my representative. <br />ZIP <br />Email <br />HOLUSP /V^r <br />Title <br />ZIP <br />ZIP <br />Email <br />Last name <br />HQLP>ERT <br />City <br />io or <br />City <br />LODI <br />State <br />_d_6 <br />IT/aW- <br />206601869 <br />City <br />lodl. <br />^Confirmation W <br />APN <br />m-Qi-v?) <br />Type of Service <br />Requested <br />Comments <br />MfeW School are <br />License Plate Number <br />First Name <br />UNCPtFD SCHOOll- mSTR-y/r <br />Address <br />ISOS' g. VlN/fc 'ST <br />Phone <br />lerformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />^)^ATE: <br />^DTHER AUTHORIZ8O AGENT <br />State <br />....6^ <br />UnfceJFAID-^iW74/ <br />Record Number ' <br />IsivO M <br />^Application for <br />Operating Permit <br />If contractor, indicate type and license ntf^^L * * <br />First Name <br />£DITH_________ <br />Address <br />DLL D • <s-r <br />Phone ! Phone <br />-33I-7-II2I <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all siteTM^^j <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified or <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAtl? <br />APPLICANT'S SIGNATURE/ <br />Facility Name <br />TlARNEe ACRDC/Vy WEST <br />-South ct/vttku <br />Supervisor District <br />1^0