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Existing Facility <br />Application Form <br />APM <br /> Repairs or Remodel Charge of Owner Consultation <br />VIN <br /> Architect Contractor Property Owner Facility Contact Facility Owner Billing Party <br /> Architect ContractorKI Facility Contact Property OwnerX facility OwnerSI Billing Party <br />If contractor, indicate type and license numberLast name <br />c \ . <br /> Architect Contractor Facility Contact Facility Owner Billing Party <br />if contractor, indicate type and license numberlast nameFirst Name <br />Z;PStaleCityAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Contact Facility Owner Billing Party <br />cast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhono <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAccepted By <br />Fee <br />UoOl <br /> Check tt <br />Rev 07/10/2024 <br />L\f\Yxcves <br />PE <br />PAYMENT <br />RECEIVED <br />Contact Types <br />required <br />State <br />ZIP <br />^>330 <br />Zip <br /><T5530 <br />pother <br /> Cash <br />Email <br /> Property Owner <br /> Application for <br />Operating Permit <br />xX P \c7vx C VCr.Vl <br />License 3late Number <br />Type of Service <br />Requested <br />Comments— <br />______V <br />If mobile food truck or <br />pumper truck <br />Date <br />to %2-S <br />Assigned To , <br />City <br />Ordinance Codes <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required JlJN 0 9 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable. I. the owner or operator of the property located at the above site adi^^iier^y authorize <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIROgjJ'^Qfl^l rH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />I Architect <br />If contractor, indicate type and license number <br />First Name <br />CiHf _______ <br />Ad^o 'Tov/rx Dr <br />Phone PhonejtoR qUl757D <br />SU“CA <br />JJ^New Facility <br />JUN 0 9 202^ar) joaqUjn County Environmental Health Department <br />san JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Site Address " ’ < 1 <br />_2100 Gwden Farims Ave-_____ <br />Supervisor District <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or pro,ecl <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 />: also certify mat ■ have prepared inis application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNT7 <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />Record Number <br />z Payment . iv-t/Xc°nf,rTOli°n8 Received By <br />^•25