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San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> l a i -,e*-t a C-C(r►'l crp-V�(nL i n 0 a <br /> Site Address 1{ C'm A O Cit k Cam state � ZIP 23 <br /> APN Supervisor District LL�J <br /> Type of Service Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Q Contractor ❑Architect <br /> required <br /> Bfff€ng Party acility Owner 01.cility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Firs ame Last name If contractor,indicate type and license number <br /> �o �a War' (?, ertkZ Tb <br /> Address City State ZIP <br /> A <br /> Phone Phone Email, <br /> 't 50405 5LP PC;Z-1 U I o e HA, �. <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> -7 <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> PAYMENT <br /> RMFIVED <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor Arc itect <br /> First Name Last name If contractor,indicate type an I ease number <br /> .qAN JOAQUIN oUN <br /> Address City state ZIIjzN\fiRONMENTAL <br /> HEALTH DEPARTMEN <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 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 FED�fidA1 laws. I / 'j /1 <br /> APPLICANT'S SIGNATURE: _ rilSi C'-ru Z _ DATE: 1r �+ L/ <br /> PROPERTY/BUSINESS OWNER ❑OPFRATOR/MANAGER M OTHER AUTHORIZED AGENT <br /> Title <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 /> Accepted By Assi ned T \ Linked FA ID <br /> c�.c.-�irt� <br /> Date J ` PE O F''ee 2, Record Number S R a 4 oc) a <br /> 142 r 111 6 ` Z 5- <br />