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T • i <br /> San Joaquin County Environmental Health Department <br /> Application Form APM 00-1;� <br /> Facility Name 1� �� . 716 <br /> ��� <br /> Site Address /, �{ i � n Cit� � � State ZIP <br /> ICAq k!�- <br /> APN ✓DUI Supervisor District <br /> Type of Service Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested perating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck :ln"IV3SS L2 w 2 I <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name ('�A � (�/��, „ L t M <br /> l If contractor,indicate type and license number <br /> IVU� —WF�-it{vt�1.- "L <br /> Address n GtyNck \ State ZIP <br /> Phone �91 Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor itect <br /> First Name Last name If contractor,indicat t pe nd license er <br /> Address City State ZIP <br /> Phone Phone Email \1\1 V 4V 14 <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 prepare d his application and ha he work to be performed will be done in accordance with III SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FED ERA aw <br /> APPLICANT'S SIGNATURE: s DATE: \, 111 <br /> YU PROPERTY/BUSINESS OWN ❑OPERATOR/MA GER ❑OTHER AUTHORIZED AGENT <br /> C 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 JOACLLI I <br /> OUNTY VIRONMENTAL HE <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. lip <br /> Accepted By Assigned To Linked FA ID r n TZD--O <br /> bate PE Few Record Number <br /> cis I-Zt12m2�4 1�34 a;tT 4.mco :�29;y 00I <br /> -Pd— l07.00 c917176?? I $2 l-I— <br /> 5-1-2,r Z2,,o�-l 2 ( -771 Zv 2,41 <br />