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❑ New Facility Tk Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> fFacility Name <br /> --Vy k" u6wvi <br /> Site Address , State <br /> )U l CA l � <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation Change or 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 0Billing Party ❑Facility Owner ElFacllityContact b Property Owner C]Contractor 11 Architect <br /> required <br /> rR Billing Party iS Facility Owner IRFacility Contact ©Property Owner ❑Contractor ❑Architect <br /> First Name name If contractor,indicate type and license number <br /> VY1 lv Y <br /> Address 7► State ZIP <br /> 2 3't 5 N 1-To" gIIcd. T'i 6�5 3-)L <br /> Phone Phone <br /> ,r;n -�L�V" a.g Yrto,, 1 . C a wt <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑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 /> MA <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Arc i eem <br /> First Name Last name If contractor,indicate type and licensOnMM <br /> Address city state zip 9Q25 <br /> J C <br /> Phone Phone Email Ife4L (►oUN <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or pro <br /> Ni <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 /> 1 also certify that I have prepared this application and that the work to be performed will be done In accordance with al SAN JOAQTV5 <br /> N COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> ❑PROPERTY/BUSINESS OWNS ❑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 avallable and at the same time it is provided to me or my representative. <br /> A cepted By Assigned To Linked FA ID <br /> Qde(li L . FAm0CD3ca-45 <br /> Date PE, F Record Number <br /> Za1 Z5 � '� Ti�9. CG(li SR2501L120 <br /> 2 T7�7 Payment <br /> El Cash ❑Check d Conflrmatinn ft,GCJ Received By , <br /> Rev 07/10/2024 ZS <br />