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San Joaquin County Environmental Health Department <br /> Operating Permit Form <br /> Facility Name �rW <br /> �..-. -•--- -- -_...----------------- <br /> QUO Munx Ceo±ne nv p --qeL-- r9- <br /> Site Address City State zIP <br /> _.W L z <br /> Business Phone SSN or Tax IDII <br /> Facility Mailing Address City State ; ZIP <br /> If mobile food truck or License Plate Number VIN f <br /> pumper truck <br /> Facility Owner <br /> First Name Las name <br /> Cem-(qj <br /> Home Address �-1�r�� � City Vl �� State � ZIP <br /> D <br /> Mailing Address City State ZIP <br /> Phone �_ Phone Emai€ <br /> Billing Party - -- — --- <br /> First Name Last name <br /> Biilin Address Clty State ZIP <br /> .2 l� '7alt/j'tP cen-t)v- 10r' ,09 <br /> Phone Phone Finau <br /> 2 7Gu"Cer ?f--e— <br /> BILLM AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant, certify that I am the Owner, Operator,or Authorized Agent of this <br /> Business,and I acknowledge that all PERMfT FEES,PENALTIES,fcNFORCEMENTCHARGES and/or HouRLYCHARGE5 associated with this operation will <br /> be billed tome at the address identified above as the BILLING AODREss for this site. 1 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 /> andlor Standards and STATE and/or FEDERAL Laws and Re ulations. <br /> Applicant Name Signature <br /> TIEIe Date Driver's License N <br /> (Photocopy Required) <br /> EHD Use Dnly <br /> Assigned To,1 r Linked FA I „h All-0 Record Number-?k h� <br /> Date PE <br /> e gs <br /> - Invelce u 5�25$b7 � <br /> Permit Valid from to <br /> Amount Paid J Paymen Received By <br /> Cash <br /> C1 Che q fILVd�, <br /> Confirms n u <br />