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Li New Facility VI, Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Nary?'" -\ <br /> boo{ (Po Pr\ e R <br />Site Address <br />/ 11/ WARN G Y Li\I <br />City i <br />L---0 11;) -X_ <br />State <br />c,,A <br />ZIP <br />9 so. -Ito <br />APN <br />o‘a.--tt i 0 - 3 <br />Supervisor District <br />0 -000 <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 61..ch a nge of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />6 kApt. yok ci e_ ooe ,--6 ---- 0 1,2... <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party .Facility Owner 0 Facility Contact otProperty Owner 0 Contractor 0 Architect <br />KcA Billing Party @facility Owner 0 Facility Contact Eil Property Owner 0 Contractor 0 Architect <br />First Name_ 1 • <br />NigNiS t T <br />Last name , if contractor, indicate type and license number <br />'7'.-C tA \ (3-3s <br />Address <br />_5-R 73 LAI° id/ vJay <br />city <br />8.c-fartvei\io) <br />State <br />c, A <br />p-\ <br />ZIP <br />?,5-83.c. <br />Phone <br />53 0 7iL3(5.,c--- <br />Phone i Email , . <br />i_oolip (At <br />• <br />in=11. CO <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />and licenseiker43,/7 ft <br />"CkIVIL ZIP ...1i, <br />Oe r <br />First Name Last name If contractor, indicate type <br />Address City State <br />Phone Phone Email 23 „ SAIN , CU, <br />hz-,--/ v Vipi,z14. <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />litspLIOPERTY / BUSI SS <br />If APPLICANT is not the BILLING <br />AUTHORIZATION TO RELEASE <br />release of any and all results, <br />DEPARTMENT as soon as it <br />I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all sit .44417/19f) <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifies g4; 74 L <br />this app ication and work to erfor.• ed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />I .- - <br />DATE: Ag /22,%/ <br />OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />PARTY, proof of authorization to sign is required <br />INFORMATION: When applicable, I, the owner or operator of the property located <br />geotechnical data and/or environmental/site assessment information to the SAN <br />is available and at the same time it is provided to me or my representative. <br />Title <br />at the above site address, hereby authorize the <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />Accepted By <br />-A--eC.--r... <br />Assi ed To <br />4.1-e-- 0 e—t--2 --jt '.- <br />Linke <br />4-A. <br />sLEA ID 00 2-G1-03 <br />Date PE <br />&•0 2____ <br />Fee <br />r? XP-c) <br />Record Number <br />5 .2.1-1 TVS q(C <br />0 Cash 0 Check # e <br />e-- <br />Confirmation Si# /T.)238,577 <br />Payment <br />Received By <br />N7. <br />Rev 07/10/2024 <br />PRociAusi-1