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M""NeW Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Abdiel Colorado Mendez B nwami C lora o Mendez/ iftacmGhnryi _ <br /> Site Address City State ZIP <br /> 505 Pioneer Dr. _115 Lodi CA 95240 <br /> APN Supervisor District <br /> Type of Service [A Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types IX Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Biiling Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Cal Central Catering Trailers!Gustavo Claros <br /> Address City State ZIP <br /> 3511 Finch Rd. CA 95357 <br /> Phone Phone Email <br /> 209-329ti3771 satas=rdinatarQca#centra#.us <br /> Giflilling Parry ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name f If contractor,indicate type and license number <br /> Address City State ZIP <br /> O Pterl r� .'c -A i! Lodi ('f� 95 2C' <br /> Phone Phone Email <br /> (20`7) -'2 6eY)voV"II I,i r'-1Ct t �S <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact C7 Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or 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 is a lica n and that the work to be performed will be done in accordance with all SAN JOAQUIN COU dinance Codes, <br /> Standards,STATE and FEDERAL I � <br /> APPLICANT'S SIGNATURE: DATE�I / I S �'f�r c Mips <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT --C'` S6 <br /> Title 7 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required SAN20a <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site: a AQjr authorize the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COU <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. D yr <br /> Accepted By _ Assigned To Linked FA ID <br /> Date PE Fee Record u er <br /> ❑Cash ❑Check# Confirmation# rn�p i Payment <br /> 2 w p Received By <br /> Rev 07/10/2024 l �[�/1 D;; O/�'/` <br />