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0 New 1.iclllty 4 Lahtlrlit I .ittlit y <br />I acuity Name <br />San Joaquin County Environmental Health Department <br />Application Form <br />fri otAti-iniA M‘Icec-, Pi ex, <br />Site Address City <br /> Slate <br />_t 20 _vJ__ t•A_A_%, 61' e Orl <br />APN Supervisor District <br />Type of Service LI Application for 0 consultation Change of Owner 0 Repairs or Remodel <br />Requested Operating Permit <br />Comments ,.. <br />—31v) C )1S1 \ 61 /\)(, N/5 DI 0,,,fla vi - cA C <br />11 mobile food truck o,r <br />pumper truck Ni - <br />license Plate Number VIN <br />ZIP <br />1536/6, <br />0 Other <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />---‘1J-iilling Party <br />—14 <br />Facility Owner Kfacility Contact 0 Proper y Owner 0 Contractor 0 Architect <br />Fint Name Last name ,—) i nolo\ <br />if contractor, indicate type and license number <br />Address <br />\ C \ Li (t) )\ A 11-0, 6e )1 e Vie_ <br />City <br />M0104 e CPs <br />State ZIP <br />Phone <br />Li 0:',-- Um -.017)? <br />Phone Email <br />rom p o-.?:&• . I'll› 0 eiiYua1t <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 pi g <br />f A/ <br />First Name Last name If contractor, indicate type and license 16?;%10E•• <br />Address City State ZIP <br />DEC 1 8 <br />Phone Phone Email <br />--EN/INRUIAl <br />SAN jOA <br />i, r <br />E7v 7- <br />VE-D <br />2024 <br />v FNT <br />A L <br />iv IENT <br />BIWNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/bci‘g?tittc,AR <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 />0 PROPERTY / BUSINESS OWNER ISLOPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <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 />putyue,... DATE: 12 h2. 2ts?•-1 <br />(EP <br />Title <br />Accepted By Vidal Pedraza Assigned To <br />Gehane Fahmy <br />Unlied_FAto___ <br />Date <br />12-16-24 <br />PE <br />1602 <br />Fee <br />172 <br />Record Number <br />0 Cash 0 Check N )i(ConfirmatIon N r-123L-1-3 7g7 Payment <br />Received <br /> <br />By , <br />Rev 07 /10/2024 <br />Payment 192843787