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APN <br /> Conwiitatwn Cl Ctunte of Owner Pepjn cw Remcdel Other <br />VIN <br />O BtBng Party JU Kilty Owner FacAty Contact O Property Owner Contractor Architect <br />Facility Owner 6.1 ng Party Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />State BP <br /> BiSing Party C Facility Owner Facility Contact Property Owner Contractor Architect <br />fim Name Last name If contractor, indicate type and license number <br />Address Qty State BP <br />Phone Phone Email <br /> BiXng Party Facility Owner FaciGty Contact Property Owner Contractor Architect <br />First Name last name <br />Address City State <br />Phore Email <br />DATE <br />JlOFIRATOR / MANAGE A PROPf «TV / BUS NESS OWNER OTHER AUTHORIZED AGENT <br />Accepted By Assigned To linked FA® <br />PE Fee Record Number <br />2-1/ <br />Scanned with CamScanner <br />Phene <br />; <br />W motSe food truck or ’ Ixense Plate Number <br />pumper truck <br />I Contact Types <br />I requred <br />Type d Senrce <br />Requested <br />Comments <br />■ Apyl < at-on for <br />Operating Perm * <br />if APPLICANT k not the BilUNG PARTY, proof of authoraatlcn to sign Is required <br />i AUTMORUA'nON TO RELEASE INFORMATXTN. When applicable. I, the owner er operator of the property located at the above site address, hereby authorue the <br />release of ary and all resmu. geotechcical data and/or environmental/ilte assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />I DEPARTMf NT as soon as a is ava.Uble and at the same time it 11 provided to me or my representilrve <br />^OvMirv <br />If contractor, indicate type and M T <br />—tw <br />__-5r <br />"NW- I phoneaoy-S'G-r/gsa, <br />Gi'yi P ■ <br />°“fy0/2U <br />-t- :?/' <br />San Joaquin County Environmental Health Department <br />_____________Application Form <br />^TncwfiS toy <br />6CA- E. y&ypi.'rc. Aft Tt/}. <br />Supervisor District <br />r—---------------------------------------------------------------- ‘ <br />1 BILUNG ACKNOWLEDGEMENT: I. the undersigned property or business owner, operator or authorized agent of same, /gs t^jt j" ' <br />specific ENVIRONMENT Al HEALTH DEPARTMENT hourly charges associated w«h this prefect or actiutty wdl be bHled to me or my <br />I also certify that I have prepared IhnjEpUMWTJnJ tSaRthe work to be performed wlU be done in accordance with ail SAN KJAQUIN COUNTY Ordinance Codes. <br />Standards. STATE and FEDERAL Z—/ OC? / -7 / <br />APFUCANTSMGNAWRf: ------------- -- " ^"" DATE: f <br />f)« ftA <br />1‘t* <br />BP _ <br />^36 <br />Vi6*v^ 2 / V/9 ^7 <br />First Name r .A IfelM O <br />Addreu <br />S'|3 <br />Last name rrtorerio <br />_________ 'wedtST# <br />Email x . <br />/>7or^o /y /b /aao 1 4 < /w