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J <br />□ New Facility 8 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />State ZIP <br />95242CA <br />Supervisor District <br />□ Consultation □ Change of Owner 8 Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />8 Facility Owner □ Facility Contact □ Property Owner □ Contractor□ Billing Party □ Architect <br />If contractor, indicate type and license number <br />Phone Email <br />□ Facility Owner □ Facility Contact □ Property Owner □ Contractor□ Billing Party 8 Architect <br />If contractor, indicate type and license number <br />State ZIP <br />95242CA <br />EmailPhone <br />□ Facility Contact □ Contractor □ Architect□ Facility Owner □ Property Owner□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />City State ZIPAddress <br />EmailPhonePhone <br />□DATE: <br />^.OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER <br />YLinked FA IDAssigned To prancjsco RujzAccepted By Vidal Pedraza <br />FeePEDate 51612/5/24 1601 <br />Confirmation #□ Check *□ Cash <br />Payment 192399752Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />Payment <br />Received By <br />Contact Types <br />required <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. /YA / . . . <br />APPLICANT'S SIGNATURE: (JIA/Up" ‘ <br />Last name <br />MUNSON <br />City <br />LODI <br />State <br />CA <br />Last name <br />VIERRA <br />City <br />LODI <br />First Name <br />RUSS_____________ <br />Address <br />2505 W. TURNER RD <br />Phone <br />209-663-9127 <br />First Name <br />JOHN______________ <br />Address <br />212 W. PINE ST. STE 1 <br />Phone <br />209-400-6080 <br />Facility Name <br />TOWNE CORNER CAFE & MARKET <br />Site Address <br />2505 W. TURNER RD, <br />APN <br />015-230-47 <br />Type of Service <br />Requested <br />Comments <br />□ OTHER AUTHORIZED AGENT 0^ <br />Title RFCFIVFnIf APPLICANT is not the BILLING PARTY, proof of authorization to sign is required L-vCIVCU <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 ENVIRONl^A9H 2Q24 <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />SAN JOAQUIN COUN <br />ENVIRONMENTAL <br />----r- —— -----------HEALTH DEPARTMEh T n^Apa^ijrr t <br />City <br />LODI <br />ZIP <br />95242