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APN <br />(I Ppptirt or Pemodnl OthnrLI (liange ol Owner <br />1 license Plate Number VIN <br />r- . na ty Facility Contact Properly Owner Contractor Architect <br /> BiUttig Party Facility Owner Facility Contact Property Owner Contractor O Architect <br />If contractor, indicate type and license number <br /> Riiiing Paly Facility Owner Contractor Architect <br />First Marne last name If contractor, indicate type and license number <br />Addrest-City State ZIP <br />Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name Last name if contractor, indicate type and license number 1 <br />Address City State ZIP <br />Phone Phone Email <br />FDate <br />[ Facility Name <br />I Site Addicv. <br />Contact Typ... <br />reoureo <br />Assigned i p <br />G.cjt <br />San Joaquin County Environmental Health Department <br />Application Form _______ <br />ZIP <br />ZIP <br />3.'?, 7 <br />It mobile food truck- or <br />rumpr t i. k <br />State <br />State <br />Oft <br />Email <br /> Facility Contact <br />F.pi <br />I o Consultation <br /><: Name <br />^<G\<ea7__ <br />Address <br />1±15_ _ <br />Phone <br />I Linked FA ID <br />I Record Number <br />wFacility Owner <br />Type of Sciviicr <br />Pecueitcd <br />, Ccmmcnt'. <br />Phone <br />V<\ <br />last napu* <br />—SlvvjVi <br /> Property Owner <br />BILLING ACKNOWLEDGLMENT: I, the undersigned property or business owner ooerator nT^mh^iT^i--------------------------------------------------------------------------------- <br />Standards. STATE and FEOEwulw’? "'"k b" Porfor.neci will be done in accordance with all SAN JOAQUIN COUNIY Ordinance Codes <br />APPUCANVS SIGNATURE- y ’ „ C . . <br />AA ~ - ---------------—------------__ DATE: 02- 6b __________________ <br />X^H'V/BUSiNFSSOZZNER □ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 0 CO <br />^WMESNVT,,nd ^Ch'“t SorS rX! 'i' SS!111 < iTri? Sa'e(l at *’**“* au'hort« the <br />1_j^AKTMENT as soon os his arable and ..............‘r^senutiye ENV,H0NMENTAL HEALTH <br />Accepted By ' r <br />- |L <br />VS-xs <br />I Supervisor Wjtrkt <br />' □ Appi'cation for <br />| Operating Permit