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San Joaquin County Environmental Health Department <br /> _ Application Form <br /> faclli Name <br /> 1 ±,3 A� c`rCiT �i' kTU� <br /> Site Address CllyS-�oc State <br /> 3bOt t FCC_ AV��� YToa CA <br /> APN Supervisor District <br /> type of servlte )R Apptication for 0 Consultation 0 Change of Owner ©Rpoairs or Remodel D Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or Llcenso Plate Number <br /> V N r. �J AAA <br /> a <br /> pumper truck S �.•�E65E.5) h Y f7 $ <br /> Contact Types JWbrkg Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required - - - — — —.l <br /> '$Btlling Party ❑Fadhty Owner ❑Fatality Contact r <br /> Property Owner ❑Contractor ©Architect <br /> First Name last name If contractor,indicate type and license number <br /> M Rco --- --- AW iA ZAD� <br /> Address CI State ZIP <br /> 360% Ate. t— Av -- 9-rxVToViij cap 5 z I ti <br /> one Phone Email <br /> h l <br /> ❑Billing Party L7 Facility Owner ❑Facility Contact ❑Property Owner G Cant:actor G Architect <br /> First Name Last name If contractor,indicate type and license numb- <br /> Address City State ZIP <br /> Phone Phone Email pq <br /> I3 Billing Party O Facility Owner 0 Facility Contact ❑Property Owner C]Contractor � n ;�� <br /> First Name Last name If Wntractor India* and I',c. ;Q <br /> �o _ g�?6 <br /> Address City State h �N CVjN <br /> Phone Phone Email --- ��T k0 S� OLN� <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 ho ly ch rges associated with this project or act evily will be billed to me or my business as identified on thL• <br /> form. <br /> I also certify that I have prepared this a plea` a e 4brk le be performed will be done In accordance with all SAN AgUIN OUNTY Ordinance Codes, <br /> Standards,S7ATE and FEDERAL laws. r, <br /> APPLICANT's SIG NATURE. DATE: �` U <br /> .Yti.+r tJT <br /> ROPERTY/BU5INE55 OWNER X151'ERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> T-tie <br /> OF APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <br /> AUTHORiZAT10N TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby a-uthorize the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> OF.PARTMENT as soon as it is available and at the same time it is provided to me ar my representative- <br /> Accepted By �1 / ` Assigned To Unked FA 10 - <br /> fiat pE Fee Reco <br /> rd Number <br /> D� <br /> - - <br /> �� in --`gV 1�r� <br />