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Is New Facility C! Existing Facility <br /> San Joaquin County Fnvironmental Health Department <br /> Application Form <br /> Facility Name n�a J D O 5 S- -e G l- 009 S <br /> Site Address I ! City State ZIP <br /> -7 3 O 5 Cot rr''Fur✓Jr'Q Sr s�►ck f�„�, cA� sz.�� <br /> APN Supervisor District <br /> Type of Service PC Application for ❑Consultation Cl Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments r } tt <br /> Fto�- av Ca LS.r <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact'rypes ❑Billing Party ❑Facility Owner ElFaculty ceritact II Property Owner n Contractor ❑Architect <br /> required -- - <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name r If contractor,indicate type and license number <br /> lek-S c[ 1r/10VIC— <br /> Address q p 1 8e L01 ( e,r) + ,q C€tY C���I`` State ZIP <br /> Phone Phoned Email J <br /> Q1efrs . M61) 0L/ GUw, <br /> 17 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 /> ❑8111ing Party ❑Facility Owner Q Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicatetype and license number <br /> Address city State ZIP <br /> Phone Phone Email <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 of my business as identified on this <br /> farm, <br /> I also certify that I have prepared this application nd that the work to be performed will be done in accordance with ( <br /> all�SAN JOAQUIN COUNTY Ordiranre Codes, <br /> APPLICANTSS TEE and FEDERAL laws. Ql�flx PATE: �/0�+ PAiYMEN <br /> ROPE RTY/BUSINESS OWNER ElOPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT RECEIVE <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign Is required MAR 2 7 202 <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorise the <br /> release of any and all results,geotechnlcal data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIR40MUDA 14 COU TY <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative, ENVIRONMENTi4 <br /> HFel TN n NT <br /> Accepted By � Assigned Ta �� (� ���rl^ Ltnked FA ID <br /> Date 2? � PE Fee �] — Rec PUy�, er0 1 — <br /> [, ]lJ�'J+ f{ Payrnent f� <br /> [ICasn ❑Check a 2confirmation el f7 l C�,4 n11G1 Q RecelVed Bx6L <br /> y <br /> Rev 07110/2024 <br /> ?(� L.-W OD2 V L, <br />