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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application_ Form <br /> Facility Name <br /> 905 Cn�0 3�L)1, off_,c, ChL4 cLIR>` <br /> Site Address City State ZIP <br /> 5 o ( � .. �-. 1rr bi.so{ �i, � b. sa[ra,tisy+�o Gib- q��z4 <br /> APN Supervisor District <br /> Type of Service pplication for 0 Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested perating Permit <br /> Comments <br /> /IAW NFF J^c Cau.^,*LJ P WRVIL F) <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck I -11v(:�-7-7CI6 V.EL Z C7D Z t7 <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party acility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Firs Name Last name if contractor,indicate type and license number <br /> Name <br /> c fej C°Y <br /> Address City State ZIP <br /> W Iv 7� f, <br /> Phone Phone Email <br /> ql& 106 '60 6?. ch 'e�C4 ra <br /> crew s—w .V-v <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 MENr <br /> Z t <br /> ECEIvFn <br /> Phone Phone Email <br /> JUN [ <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor �NA,Raaf[3E�4fN OANTY <br /> IL <br /> First Name Last name If contractor,indicate type an is NT <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 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 laws. ] / <br /> APPLICANT'S SIGNATURE: ? 1 n nc� / DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑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 /> A ID <br /> Accepted SY7ePon C. Assigned Torra?as C.D A L-Jt�d FW?47C8(aDate Z P£ Fee Z mm Record TVumper � <br /> z�r A P Z1F005 <br /> � � 7 <br />