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)1 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Lk) e__.•(\3, 5 \Oct tce A (,)CC‘c-=N <br />Site Address City State ZIP <br />3'i cr-.35-0\ S\ tlic.,_ cf -r._ Cc.,_ q5 3 3 ..-- <br />APN Supervisor District <br />Type of Service 0 Application for 0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Requested Operating Permit <br />Comments <br />If mobile food truck or License Plate Number VIN <br />pumper truck <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />pig-ling Party /El Facility Owner ,0•Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />(A.) -e_,•(\ c..\., L. <br />Last name If contractor, indicate type and license number <br />Address <br />5 3 1/ Ccus--c-A. \- <br />City <br />1\1\ ax)\-erc- <br />State <br />C_c, <br />ZIP <br />q 33 S. <br />P one Phone ti mai l <br /> 6 ,,, ,f,,,, ,A cc.,:‘ \ • co ^-) <br />) <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 .41 iM, <br />First Name Last name If contractor, indicate typltri license nu e i <br />L 18 <br />Address City State tNvin, ,., <br />P Ritili <br />ilt-th4e,/,.. <br />24 Z I P . <br />. 1 AL / <br />Phone Phone Email r/SEirjoi ,vicEs - <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 FEDERAL la s. <br />APPLICANT'S SIGNATURE: , - C DATErN 2 - .r* <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT to <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 />.1 <br />Accepted By(1J\ Assigned To f '.k,.....z4 <br />N 144-0 <br />Linked FA ID <br />pc...a t- e— 1 till 7 4, 7 A wEL. tk, 0 1 Fee 11 50 <br />..A. <br />Record Number <br />pp2goal 35. <br />0 Cash <br />N <br />0,Check # 0 Confirmation # <br />Payment <br />Received By <br />Rev 07/10/2024 <br />PeZi 00110