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New Facility <br />S-v-aqP <br /> Repairs or Remodel Consultation Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Own Contractor <br />t^d*lling Party Architectfacility Owner O Property Owner Contractorfacility Contact <br />If contractor, indicate type and license number <br /> Architect Property Owner Facility Contact Facility Owner Billing Party <br />numberIf contractor, indicate type and been <br />DPState <br />Cu <br />O Property Owner Facility Contact Facility Owner Billing Party <br />Last nameFirst Name <br />StateCity <br />Address <br />I Phone Email <br /> <br />Phone <br />DATE <br /> OTHER ALFTHORIZEO AGENT <br />T.tle PROPERTY/BUSINESS OWNER <br />I <br />Feei - <br />^Conf-imat on fl <br />j - - - ""ncr> v » <br />Reir 07/10/. <br />I <br />I <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br /> Contractor <br />DP <br />3) <br />'^Existing Facility <br />San Joaquin County Environmental Health Department <br /> Application Form o\'oi, 1^^ <br />State <br />IHChange of OwnerType of Service <br />Requested <br />Comments <br />P*YMEnt <br />'■gC r'i J' or operator of the property located at the above s te address, hereby authorue tne <br />- fryn-.! on ' • *he SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> _! <br />(Sj c^ffxxzA • <br /> Contractor <br />Facility Name <br />-—STdP S.WOP rA^RT <br />Site Address ------ <br />—C. P><€»ncK CQrv\j|o RgL:_____ <br />APN Supervisor District ’ <br />City <br />State <br />I Architect <br />Phone ' ■■ <br />- applicant .S not tne till‘'“J................ W/ the <br />AUTHOR.ZAT.ON TO RELEASE IMORMANON <br />! release of any and ah result^ atthe same t.me .t .s prow; <br />I DEPARTMENT as soon as.t isavauj--------------- <br />"tbOT. |r——--------------~~~~~ T <br />Date <— <br />I * ■ ■ — <br /> CashI--------------------- <br />3&S •€ fverCK Cor^jo ■ <br />Phone Phone Emagvwri-mx ll <br />form J •uu-.fuw that the work to be performed will be done in accordance with ail fcAl <br />l also certify that i have prepared th-sap^cafon apdlhat the worktooep <br />Standards. STATE and FEDERAL UwJ I /KA- DATE ----------4- <br />APPLICANT'S SIGNATURE---------4J > <br /> OPERATOR / MANAGER <br />FirsLUame . <br />First Name <br />Address <br />,N JOAQUIN COUNTY Ordinance Codes <br />ooooofe3 i <br />R?WgL5014G? J <br />If contractor, indicate type and ' ' <br />DP p-