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fl New Facility Elv Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name _7., l j ) yr irrl ( e.c F(f.(.e Site Address "( 2-1 30 (2 r,.1 C.( lAk L Iti City q0 0.:.-foi, State cA ZIP 92° 9- APN Supervisor Districi-1 Type of Service Requested VKpplication for Operating Permit 0 Consultation 12<hange of Owner 0 Repairs or Remodel 0 Other Comments CIA&Plcsr_ Tlti c1-'1A-0“Liv‘ If mobile food truck or pumper truck Liinse Plate ber VIN Contact Types required 0 Billing Party 0 Facility Owner 0 Facility Contact Cl Property Owner 0 Contractor 0 Architect 0 Billing Party lit/Facility Owner El Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name,A / 7116V Last name If contractor, indicate type and license number Address 2 I .3 0 C 0 ut , c:/tAb ,J3Iva? . City, 7 , 5 rocef»-1 State CA ZIP 7f 2 4 Phone Phone ( Email 0 Billing Party 0 Facility Owner 0 Facility Contact El Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and licens Pi• M Address City State ZIP Sp n Phone Phone Email u 2m, sAN Jo , vo ke..ENVI/V(IN CouN7 Li Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner Li Contractor LlkiifitiVii'TIVT PAR T. 41.. IITAir First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepaped this application and that the work .:,... - performed will be done in accordance with all S. N JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDER L I,aws. I 1 DAT? 0 APPLICANT'S SIGNATURE: 2/PROPERTY / BUSINESS OWNER Li OPERATOR / MANAGER Li OTHER AUTHORIZED AGENT Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Accepted By i Assigned To ' Linked FA ID /---7---).(zavti -7-0 Datea, i 1 PE L 60 L. Fee rl. 2_. , RecorcOurnber b f.., 2_44 cbcp 4 •-0 0 Cash 0 Check #onfirmation , /C # 7' 7crr c:.-Li-g 7 l Payment Received By pgolvD318 Rev 07/10/2024