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San Joaquin County Environmental Health Department <br />Facility Name <br />State ZIPCA 95337 <br />APN Supervisor District <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />^Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />Last name If contractor, indicate type and license numberDhillon <br />Address State ZIPCA 95337 <br />Phone <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 />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />First Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />DATE: <br />★operator / MANAGER□ PROPERTY / BUSINESS OWNER □ OTHER AUTHORIZED AGENT <br />Accepted By Assigned To Linked FA IDt- <br />Record Number <br />Director of Operations <br />Title <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 available and at the same time it is provided to me or my representative. <br />Email <br />Dliillon.aman2@gmail.com <br />WApplication for <br />Operating Permit <br />Phone <br />(209)249-0800 <br />Type of Service <br />Requested <br />Comments <br />_________Application Form <br />Staybridge Suites Manteca <br />First Name <br />Avtar <br />1878 Daniels Street <br />□ Architect <br />If contractor, indicate type and license <br />*§CEiyEr <br />MAY L 7 202i <br />--------------------------------------------- ---------------------------------------------- ------------------------------ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site TMENT <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 COUN1Y Ordinance Codes, <br />Standards, STATE and FEDERAL laws. S/71 /?074 <br />APPLICANT'S SIGNATURE: '_______' <br />1V y/6A^ /$/ 202-4. <br />sueAddressj Daniels Street <br />City Manteca <br />CltY Manteca <br />Fer. <br />24