Laserfiche WebLink
On/12/2024 kokok LAcks igi.Co, <br />diat, is31.64413 <br />DATE: 0612.51.2624 Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />Oto?)er 0 OTHER AUTHORIZED AGENT <br />Ob I k2.• "°°2-- <br />Record Number <br />Linked FA ID <br />F 1002L1362. <br />sc4'2_,-1002-12- <br />0 New Facility J1 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form 9oS,-1 2S 1-4 <br />Facility Name <br />Desi Piz2_A Gi -re <br />Site Address <br />2511 N TizAc SLV f) <br />City <br />TR A CY <br />State <br />CA <br />ZIP <br />46316 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation )it Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />— <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />_ <br />0 Billing Party X Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />AA WA/0 Eg <br />Last name <br />(SEKHZ/W <br />If contractor, indicate type and license number <br />Address <br />/766 Feeie <br />Phone <br />q2-5-32A---.9qe.5 <br />street- <br />Phone <br />City <br />Makit-e e A <br />State <br />CA <br />ZIP <br />95 337 <br />Egiail . <br />desil)12.24 bfre _ 'rad. am <br />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 <br />PA)(44First <br />0 Contractor 0 Architect <br />and license <br />fwb <br />Name Last name If contractor, indicate type <br />Address City State ZIP <br />JUN 2 , <br />Phone Phone Email s <br />6 <br />ANjn, < <br />— EAli;7,ziQl. fin, — <br />Nr <br /> <br />024 <br />"EALrlirl'c)NMp Lilvry <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or p R 7-4,77:4E1-NT <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 applic on and th4 the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes. <br />XPROPERT! / BUSINESS OWNER CI OPERATOR / MANAGER <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 />Title <br />Accepteo By , <br />("\ Nr\o\r <br />Date PE <br />Assigned T9. <br />C7\. e <br />Fee <br />-2_