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San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name JJ S ASiAM Cl/) kSJHF <br />State ZIP <br /><15337(Sa <br /> Other Repairs or Remodel Change of Owner Consultation <br />License Plate Number VIN <br /> Architect^facility Owner Contractor Property Owner Facility Contact Billing Party <br /> Contractor ArchitectjXFacility Owner Facility Contact Property Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />Joce'tN n <br /> Architect ContractorEfFacility Owner Property Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast name <br />Email <br /> Architect Contractor Property Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />ivlllzoz*DATE: <br />^PROPERTY / BUSINESS OWNER OTHER AUTHORIZED AGENT <br />Title <br />PE 1^/ <br /> OPERATOR/ <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />-PAYMENT <br />RECEIVED <br />Phone <br />(U^l) <br />Phone <br />^^ -72% <br />ZIP <br /><753 3 D <br />^'Facility Owner <br />Type of Service <br />Requested <br />Comments <br />Email <br />2027 61 MAj <br />Site Address <br />/ 3? 5 c • m >Tr a <br />APN <br />Gam. Mfr <br />City <br />azanfECa ca-^533? <br />Supervisor District <br />Phone <br />ZIP <br />City <br />State <br />(LA ■ <br />MANAGER <br />State <br />CA' <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 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 />APPLICANT'S SIGNATURE: <br />Assigned To <br />Giq I F- _______ <br />Fee^537.^(3 I fey?.- <br />paidcSI W«5cI73-tW' <br />Accepted By <br />—Gi^gi- <br />D3t/^/^s <br />Address <br />) 507 <br />City <br />First Name <br />Joy_________________ <br />Address <br />Phone <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, herefcrUjUth^jizp tf$J/{| <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.______________________________SAN JOAQUdJ^-GQUAITY <br />_________________environmental <br />Linked FA ID HEALTH DEPARTME NT <br />EA00OO3 _______________ <br />Record Number <br />SR25 01635