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0 New Facility X FxisVng Fac!lity <br /> San Joaquin County Environmental Health Department <br /> Application Form W,'OS0, S - <br /> Facllity Name <br /> PAPA �v�PK '4 Q,z�.a � <br /> 4 Site Address _ --- <br /> Z''Sb �ETTi.EMgT� LANE -�# 10Q ! 1.afl GA Ct52-Li2. <br /> APN <br /> Supervisor Distrct _F —— i <br /> Type of Service ❑Applsca[ion for ❑Cansuitatior —— — y <br /> Charge of Owner ❑Repairs or Remodel i i.:Uu <br /> Requested I Operating Permit <br /> i Comments <br /> If mobile food truck or License Plate Number <br /> pumper truck NI� <br /> - _ p 131l11n6 Party Facility Owner 0 FaciCtty contact ❑Property Owner ❑Contractor ❑Architect <br /> ❑B!`'re P""V a Facility Owner I ❑Fes- acility Conidtt ❑Property 6 ner ❑ oC ntractor ❑Architect_ —-- <br /> i Firs:Name - �— --- Last name —� <br /> It contractor,indicate type and license nurnt:er <br /> was�c4pER Ks. t_.ot� <br /> Address State :'" u <br /> Ai�'Z.o LYaRTfl Rn 1 Ae�T EuOPE �A q S%L13 <br /> Phone Phone12 - - <br /> Sdiing Party � A Facility Owner G Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor.indicate type and license number j <br /> ax vote ^JI <br /> A�CresS City State ZIP <br /> ti�S2,Q F L_vex tT� �.v 1 ArTE�e� �q 95'8Lt3 <br /> Phone I+� Phone — u <br /> 91 4-A41Z.•- 49p % i Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 13 Property Owner ❑Contractor ❑Architect �� 1 <br /> First Name Last name If contractor,indicate typ nd license number <br /> address City State l�f <br /> C i11& r <br /> Phone Phone Email 1 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,ackno Q� d or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or actwity will be billed to me o l <br /> form EP rq� <br /> I also certifythat f have prepared this dp liedtfon no that the work to oe performed will be done In accordance with al}SAN JOAQUiN COUNTY CriNrjr c, s, � <br /> Standards,STATE and FEDERAL laws. w _ <br /> APPLICANrs SIGNATURE: DATE: <br /> APROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT SECRrsT ARC <br /> Tit!e <br /> If AVPLICANT is not the BILLING PARTY,proof of autt.of.aaV n to sign is requires? <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,gectechnical 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 tome or my representative. <br /> Accepted By Vidal Pedraza --- Assigned To Francisco Ruiz �a ID <br /> Date 7-2-24 Pe 16O2 Fpe 172�--------_�— Fletord Number a 4 (2)(2)Q 5 <br /> Rev06/12/2024 Pkt Co. F10.Mv►T I en1 $ 1$Li O 35 ii S �� !�'� •� <br />