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- New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name 4 <br /> Tna; oLvi Pam Zaso- Kk; Mel a <br /> Site Address City State ZIP <br /> `7 t 0 E. Woodward Ave. Ma.n+ec� CA g533-7 <br /> APN Supervisor District <br /> 11 <br /> Type of Service KApplication for I❑Consultation ❑Change of Owner ❑Repairs or Remodel II Other <br /> Requested Operating Permit <br /> Comments <br /> T-e-�ll ip v e rg+- <br /> If mobile food trick or License Plate Number VIN <br /> pumper truck <br /> f Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ill[ng R i llty Owner ❑Facility Contact ❑Property Owner C7 Contractor ❑Architect <br /> First Name's Last name f If contractor,indicate type and license number <br /> 0117 <br /> Address <br /> Phone Phone Email <br /> � '/ o l5- SIO-Olol 't 4 cU• Ccr� <br /> ❑Vling Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name It contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party G Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Archite6Li <br /> First Name Last name If contractor,indicate type and lic tFe <br /> Address City State ZIP p E <br /> Rp <br /> 1. <br /> Phone Phone Email <br /> Vj�,Q N C`p <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that al!site and t <br /> �qf <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�T <br /> form. <br /> I also certify that t have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY ordinance Codes, <br /> Standards,STATE and FEDERAL laws, <br /> JAPPLICANT'S SIGNATURE: Z , <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <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 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 /> Accepted By C . Assigned To f I Linked FA ID <br /> Date^ 1 a G PL 1 & O Fee { Record Nurser I a 5o i S 5 <br /> Payment <br /> � <br /> ❑ it Cash J 0 Check f! 1 Confirmation ZI�1 Z� <br /> fff Received By <br /> Rev 07/10/2024 <br />