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Gut ileti Isc'T (-0 ric 9--pcciti(Y,A6 <br />Strpenilsor Clistrirt <br />MAnkerct C A Oly <br />_k) IC) Vayrit AVe clot. <br />APN <br />q .53S6 _ <br />Type at Sernce <br />Requested <br />fl Appluation for t CensulOtion beige of Owner <br />Operatine Permit <br />0 Repairs or Remodel <br /> <br />0 Other <br />0 BiftV,g Party j OlflyOwnyr 0 faolnv ContOrt <br /> <br />0 Property Owner <br />0 armraCtor 0 Arc feet I Coated Pypei <br />required <br />,APer &ii F <br />To (1,4 i00 r" <br />Tdb c)0 172oo <br />VRO Ito - <br />San San Joaquin County Environmental Health Department <br />Application Form <br />Comments <br />met.* food trueir tra.enve Plate Number vol <br />pumper truck <br />r 0 Bang Party 0 Facility Owner <br />1 5— <br />0 FacRity Contact 0 Properly Owner 0 [entracte 0 A0&tf <br />I First Name <br />I Lk <br />test name <br />(A)etel- r '‘ \ If ContraCtor. lerdreate TYPe and license number <br />AdOtess oty <br />7. lei Skl Ifni D r -Vrok ckt <br />State C Pr P qs3'61 <br />FIrOre I, Mot* <br />I3S .411051 <br />Eelail s Si <br />e,e(Cf r'N StKellh5 2..G g TOICii tor' <br />0 Meng Party 0 Fichte Cromer CI Facility Carsten 0 OtePeny Owner 0 Contrattar 0 Architect <br />First Name LAM name if contractor, indicate type and license number <br />Addreu CIty State ZIP <br />Phone Phone C ' <br />0 Biding Party 0 rankly Owner 0 Facy Contact 0 Property Cermet 0 Contractor 0 Architect <br />i irst Name Int name it contractor, indicate tvne and license Tiim,Ret <br />Aradterz CIty State ZIP <br />PAone PhD tonag <br />fittiPeGnetflOWUDGCMIttir: <br />%octet f NytfoaaimEtstAt <br />form <br />I s'so certify that i have torniited <br />Standards. Sint( and r 1 (ARAI <br />APPOCANY'S SJGNATURC, <br />.), priori Ri v / RuStritS5 <br />I? rum/cast in not ow PALING <br />numaneAllOrt 70 RELFASE <br />pei.,ease of an t and all fe Wilk <br />c4 F AR DANS a s WW1 a s <br />I, the under tiened Property ot bow It Owner. OPFaiOf Of authonted agent of tame, acknowledge that an site and/ot wenn" <br />hc"410 hag <br /> <br />141ALTti Of prortmENT es as . test With this pro)ect Of activity will be billed 10 meet my bUSife id eSS as identified On ttui <br />this bpi:Acetic At .,,,.. to performed will be done in ercordance with all SAN ioActuer4 COUNTY Ordinance Codes, r . laws. <br />f y, <br />..raPitir CAM 1/._as22-1/ <br />orraiNf A rump / MANAGER 0 cuff P. AWNOPIZIOAci(111 <br />PANTY, proof or authorizatiori to sign ts required <br />INFORMATION: When applicable, t, the owner or Operator of the ptutterly touted <br />seciestunial data and/or envirerinleritalisite 491estmefli informayon to the SAN <br />it is available and at the same time II is provided to me ot thy reptesentative. <br />Title <br />at the ahoy. site address, <br />10AQUiN [MOM INVIRONINCNIrat <br />hereby authorize the <br />}RAIN <br />',A add <br />tanked FA 10 fizi 15) 0 1.4..] <br /> <br />u'n2—tis Olga I - 1 <br />41c71 -73 1101 PAYMEN T, <br />RECE/vED <br />NOV Zo 2024 <br />SAN JOAQUIN <br />COUNTY LS' ENVIRONMENTAL HEALTH DEPARTMENT