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PR250094 S $ New Facility <br />San Joaquin County Environmental Health Department <br />^535/ <br />Supervisor District <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />□ Property Owner □ Contractor □ Architect□ Facility Owner □ Facility Contact <br />52 Billing Party ® Facility ContactJ3 Facility Owner □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />imail <br />□ Property Owner □ Contractor □ Architect□ Facility Owner□ Billing Party <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPCityAddress <br />EmailPhonePhone <br />□ Property Owner□ Facility Contact□ Billing Party □ Facility Owner <br />and license numberLast nameFirst Name <br />CityAddress <br />EmailPhonePhone <br />DATE: <br />□ OTHER AUTHORIZED AGENT .NAGER□ PROPERTY / BUSINESS OWNER 'Fl <br />Title <br />Linked FA IDAccepted By <br />□ Confirmation tl□ Check «□ Cash <br />Rev 07/10/2024 <br />□ Existing Facility <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />J3 Application for <br />Operating Permit <br />Payment <br />Received By <br />Type of Service <br />Requested <br />Comments <br />Record Number <br />Phone <br />License Plate Number <br />□ Billing Party <br />Ejrst Name <br />GAgCiFC <br />Address df <s\\( tA <br />, Phone-. <br />’OArchilec? <br />jrhusiness owner, operator or authorized agent of same, acknowledge that all site and/or project <br />^esVsociated with this project or activity will be billed to me or my business as identified on this <br />1552^ <br />wofk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />0'71^512^ <br />Da,^\z5\i5 <br />State . <br />f 4 <br />If APPLICANT is not the BILLING PARTY, prSofofJdthorization 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 HEALIH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />State <br />CA <br />PE <br />Assigned To^ <br />Fee $n9.<Z)(D <br />Last name , <br />CitY <br />197-5 ^0^ <br />□ Facility Contact <br />Application Form <br />facility Name Z1 f I / <br />TriC05 P 097^4^ y tv <br />Site Address , ' Trit2 <br />1211 S S-F______,_________, <br />APN <br />BILLING ACKNOWLEDGEMENT: I, the undersigned prod <br />specific ENVIRONMENTAL HEALTH DEPARTMENT KotlrlV <br />form. ’ <br />I also certify that I have prepared this application anXth. <br />Standards, STATE and FEDERAL laws. /\ A <br />APPLICANT'S SIGNATURE: / <br />J <br />S^t^niuctor, indicattVfcS