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0 New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />10.1111111, CXCk. WZA Vk C O' \--(1. Cl Niat\eke . <br />111111111 Ci_c . 11(91 D vmk-o s* c\-rx.\\ IIIPL-cdt <br />tts c <br />-2-14 0 <br />APN Supervisor District <br />Operating Permit <br />ili! r <br />Type of Service <br />Requested <br />0 Application for 0 Consultation XChange of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck •tA i -YCFP) IMP 1. 6 -1‘'P 7 IL OL37' (5",d,q C3 <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />`y:1 Billing Party IN Facility Owner I X Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />ININgibte\ <br />Me-oscio <br />If contractor, indicate type and license number <br />1111/116‘ t- l.(5,'VeVA\).e. 1111 A-Dc,v,\-oc\ at c ,N 70‘ r3-1..A.0 <br />impkt,-,o Phone <br />!IliTeAM (193-\z•)‘ CF-E \ cick.La . eDiy) <br />0 Billing Party 0 Facility Owner j4Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name M\e, , Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone <br />(2l'3-29f -- 0e3 Phone <br />-'f <br />Email <br />Ate(' Vll CAA-0 M)--i .\ (-VA) LOrn <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name r 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Orclai4elehiesv. <br />Standards. STATE and FEDER aws. <br />0 PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT <br />Title 4 i 4/24 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 84/V 'OAOu <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addrespip R6 ilidaeltiN,,, <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRON hfottig j...14/vr,A, ' r <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ---' ARTAelv., <br />Accepted By Ass <br /> -,rici, co 12. ,,.kilttri),6...56.1. <br />D I .1 \ OA ZLI PEI (10(95 <br />F ee $ \12 (in 4,(wi__, Rgrlitt_ii 4ntri-oci) <br />pM co - loiD(2q- Rey 06/12/2024