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AP# <br />Facility Name <br />State <br />Facility Owner <br />fl LQiLiCH <br />I 2-4-f ^7 -7 7i <br />Billing Party <br />P L CH <br />^77 7j 4.4- 03 <br /> <br />Signature <br />i-5C3r^5-36jI 7 02)rv(T't- / <br /> <br />EHD Use Only <br />Record NumberLinked FXk ID <br />FeeDate SLoM - <br />lnvc.ce s <br />^■so-Permit Valid from to <br /> Cash <br />ZOA \ ii>S SO'o <br />t'o'S - <br />T'e ^''oLeric ; ^.Q <br />)jf\/ZCH fi-0 , if 6 <br />'2-Vo‘SMO <br />\5 .00 <br />PAYMENT <br />RECEIVED <br />ZIP <br />Last name <br />/<y? t 'H/l & rJd <br />Amount Paid <br />City <br />VIN <br />JcL <br />v4 <br />Phone <br />,5 I o <br />State <br />SSN or Tax ID# <br />ZIP <br />First Name <br />a <br />Home Address <br />K 7 4^- <br />Mailing Address <br />/ 4-4- <br />Phone <br />fl- <br />?<- <br />Phone <br />‘A ■ 25- ZS oYvxr^ eCT.b''e <br />Bev 06/12/2024 VeoK Cf’e <br />State <br />ca 1 <br />Email <br />U C ^7Y?<?>. i • C <br />S ucPgulc^Qaafi <br />s^xAcAkAV <br />geecxXV <br />I bp ' 1 <br />ZIP <br />^53 / <br />ZIP <br /><7/5^/ <br />Driver's License M <br />(Photocopy Required) <br />Site Address <br />470 <br />Business Phone <br />^•/O 7 7 7 <br />Facility Mailing Address <br />^70 <br />If mobile food truck or <br />pumper truck <br />a\d CovpLiANCE Acknowledgment: I. the undersigned Applicant, certify that I am the Owner. Operator or Author-zed Agent of <br />Business and acknowledge that all Permit Fees. Penalties, Enforcement Charges and/or Hourly Charges associated with th 5 operation <br />be billed to me at the address identified above as the Billing Address for this site. I also certify that all information provided on this application <br />is true and correct and that all regulated activities will be performed in accordance with all applicable San Joaquin County Ordinance Codes <br /> and or Standards and STATE and-or Federal Laws and Regulations. <br />Applicant Name <br />__ £>/77/9 rv 6___gq ___ <br />Date <br />O <br />P (1 2S <br />San Joaquin County Environmental Health Department <br />Operating Permit Form <br />_A®^-(^\vcaacp L_CC <br />City <br />_______-SEP 2 6 2025 <br />____________SAN JQAQUIN COUNT <br />Payment Received t».*'V)RONMENTAL <br />HEALTH DEPARTMEN- <br />LZ <br />Title <br />o <br />1_______________________ <br />j First Name <br />i 42/77/9/V c <br />{. Billing Address <br />.-/4 4. p~ <br />Phone <br />7 'c- <br />City Trf.* c 'o <br /> Check # <br />. "^Confirmation « <br />SO <br />State <br />Crt <br />State <br />____ <br />Email <br />Last name <br />/C/? <br />City <br />City <br />7 Mei <br />67/ 4-4-°3 <br />Assignee <br />Lx ynVXcaZ <br />License Plate Number