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Facility Name <br />Supervisor District <br /> Consultation Change of Owner Repairs or Remodel Other <br />H i cao <br />H Billing Party Facility Owner 0 Facility Contact Property Owner Contractor Architect <br />0 Billing Party Facility Owner Facility Contact Contractor Property Owner Architect <br />If contractor, indicate type and license number <br />Phone Email <br />H Facility Contact Property Owner Contractor Architect Billing Party Facility Owner <br />If contractor, indicate type and license number <br />Phone Email <br />rob.daly@ compass-usa.com <br /> Architect Contractor Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />Phone EmailPhone <br />6/12/2024DATE: <br />0 OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Linked FA IDAssigned ToAccepted By <br />O <br />Fee <br />I Property Owner <br />I <br />Date <br />_____I 'Vk ______ <br />I <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 />If mobile food truck or <br />pumper truck <br />0 Application for <br />Operating Permit <br />ZIP <br />28217 <br />ZIP <br />95354 <br />ZIP <br />95304 <br />Last name <br />Rollins <br />Last name <br />Daly <br />City <br />Modesto <br />State <br />NC <br />State <br />CA <br />State <br />CA <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. <br />APPLICANT'S SIGNATURE: <br />Site Address <br />1500 E Grant Line Rd <br />APN <br />Type of Service <br />Requested <br />Comments <br />First Name <br />Nicole <br />Address <br />2400 Yorkmont Road, Attn: Licensing <br />Phone <br />704-328-5521 (officle) <br />First Name <br />Rob__________ <br />Address <br />542 Mariposa Road <br />Phone <br />209-346-1231 (cell) 209-287-3771 (offic|e) <br />Licensing Manager <br />Title <br />Canteen @ Amazon SCK6 - Remote Market__ <br />City <br />—Tracy <br />foxbw, <br />VIN <br />City <br />______________Charlotte_______ <br />"Nicole. Rollins@compass-usa.com <br />License Plate Number <br />CcWf U S < <br />|PE l(pO2-^X’pzHoosoq <br />Contact Types <br />required <br />PAY/WEfy-r <br />p/T Received <br />San Joaquin County Environmental Health Department JUN 14 202^ <br />Application Form_________ <br />MtALTH department-