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San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name T <br /> Aock S CJAO��se �f,-'afe-f <br /> 51[e Address Ciry o- State zIP <br /> P H;s t zr;C.P Igza M 'k� 9- 36 <br /> APN Supervisor District <br /> Type of Service R Application for Consultation ❑Change of Owner ❑Repairs.or Remodel 1:1 Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types illing Party / Facility Owner ELFacility Contact property Owner ❑Contractor ❑Architect <br /> required. <br /> Q Billing Party ❑Facility O caner Q Facility Contact ❑Property Owner Cl Contractor ❑Architect <br /> First Nam ]] 1 last name } if contractor,indicate type and license number <br /> �L21 i'1 f�J u Q.h <br /> Address ' C€ty, 1� � Slate C n ZIP � � <br /> 1333 14',s-F�r� pta� r�1� II IT <br /> Phone. 2` �Z Phone Email� M eri�1} f <br /> 5 �„ tNi 1 i rr G�'t'vl <br /> ❑Billing Party Cl Facility Owner ❑Facility Caniact ❑Property Owner ❑Cortracter ❑Architect <br /> First Name Last name If contractor,indicate type and 11ce <br /> Address City state ZIP CEO T <br /> Phone Phone Email GJOA <br /> v�+ <br /> rJ <br /> ❑Billing Party ❑Facility Owner ❑facility Contact ❑Propeny Owner ❑Contractor `�tlU <br /> First Name Last name If contractor,indicate type and licen <br /> Address City State ZSP <br /> Phone Phone Email <br /> B[LUNG ACKNOWL£DGEMENT;1,theundersigned propertyor businessowner,operatcror 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 ;lli- ti�d that tls rk to be performed will be done in accordance with all SAN OAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE-and FEDERAL law. <br /> APPLICANT'S SIGNATURE: PATE: <br /> 7 ROPERTY/BUSINESS OWNER z PEfiA OR/MANAGER ❑OTHER AUIHORIZED�GEPi7 <br /> r Title <br /> H APPLICANT is not the BILLING PARTY,prooF of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 to me or my representative. <br /> Accepfed By Assigned-Ta /� Linked FA ID rf4 0016 3 6 _ <br /> Date PE F 1 L [,DO Reca R- S(r���m J <br /> i6 2 �L G <br /> PR62 H��� <br /> s <br />