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Pt2-.050(6 L <br />r MEAPV. San Joaquin County Environmental Health Department rIE'Covit; <br />NAY z <br />3 2 <br />Ty <br />NT <br />Application Form <br />Facility Name " j°,AQU <br />OA/mp. L L c HEAL <br />Site Address N <br />/ 1 1 1 <br />C ck vt.,:trir. City <br />5---trigito-A <br />State <br />GA- <br />ril ZIP DEPARN A 7-4,7s <br />15 2_' oc.:, <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 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 />'Contact Types <br />required <br />0 Billing Party Olacility Owner 1:1-ra-cility Contact D Property Owner 0 Contractor 0 Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Firpmet , <br />L C (-0.- <br />Last name <br />'VIM ‘.--,...,(e__S - e...-er0 A-4.- 01 0 <br />If contractor, indicate type and license number <br />Address <br />...t .7 SL A g 12)e,A.,e--kit cco <br />City <br />5tbcg--TO V\ <br />State <br />Gt.i- <br />ZIP <br />qSz_o(c7 <br />Phone <br />7451-• (n7,,--LVD___ <br />Phone Email <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 <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <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 pplication and that the work to be performed will be don in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. -- <br />APPLICANT'S SIGNATURE:- C DA-vco 5 .9 ki <br />eporiCOPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 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 />By Assigned To Linked FA ID <br />bat I Dat <br />(42:1)1 2A <br />PE <br />I 6° <br />Fee Record Number <br />ScZ2-44 VI) i Cic0 <br />Po't ko2,0a