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❑ flew Facility Existing facility <br /> N <br /> San Joaquin County, Environmental Health Department <br /> Application Form <br /> FaClFity Name <br /> AT&T California UGO10 <br /> S1teAddfe5s City State ZIP <br /> 1812 Coley Ave_ Eswlon CA 95320 <br /> ARN Supervisor District <br /> TypeofSer Ace 0 AppIPcatlon for 13 Consultation L;Change of Owner R RepalrSor Remodel ❑other <br /> Requested OperwIng Permit <br /> Comments <br /> Secondary Containment <br /> If moblle food truck or ucense Plate N umber VIN <br /> pumper truck <br /> Contact T'ym 0 elmir%Party a Fa[111ty t}wner 0 FaclUty Contact 0 Property Owner ❑Gontrartur ❑Architect <br /> required <br /> BII ling Party 0 Fad4ty Owner f]Paeulty Contact d Property Owner On r actoe ❑Architect <br /> L <br /> Flrsi Name Last name if ronlra[tor,indicate type and Ilcense number <br /> Ernie Bravo for TAIT Env[ronmental A-IJAZ-5881758 <br /> Address city i Mate ZIR <br /> 15012 Zieglinde Dr Lake Elsinore CA 92530 <br /> Phone Phone Email <br /> 626-B27-0072 msherley'tgr@yarloo corn <br /> ❑Belling Parry ❑FaclYty Owner ❑Facility Contact ❑Property Owner C]ronrra0pr 13 Amhllect <br /> First No me Last name if aantractor,ir,&caae type and licanse number <br /> gddres5 City State Zl <br /> ptmve ph(me Emal1 <br /> C]P11111ngp rly CFadlityOwner ❑facllltYConw b;trope rtyOwner ❑Cem4rattor 13Archfted <br /> First Name Last name If contracWr,Irw0cale type antf I4ce+t5e number <br /> Address City State ZIP <br /> Phone Phone Ernall <br /> BILLING ACKNOLVLEOGEMENT-1,the undersigned property(W buslemm UwYwr,operator orauthorlred agent a€samer acknowledge that all site andfOr projeCl <br /> ipecific ENVIRONMENTAL HEALTH DEPARTMENT hourly charVsassoclated with th19 prmlect or actl^will be billed to me or my businessa5 Pdere#lfiad pn 1h15 <br /> form_ <br /> I also certify that I have preps red this appPlcation and that the work to be performed will be done In accmdanre µnth all SAN JOACWIN COUNrfY Ordlrrartce Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICAWS SIGNATURE: BATE' 99-j;, <br /> f]MPEATY/BU5lNM OWNER M OPE PATOR/MA EA 0 O7HER AVtH0R4?EO AGEM w""r F� <br /> TIUe <br /> tf APPLICANT P5 not th2 BILUNG PARTY,prppl of authoriaalion W sign Is required <br /> AUTHORIZATION TO RELW� INFORMAWN:When uplewble,I,the owner OF operator of the property located at tha above Ote address,hereby authorlac the <br /> release yr any and all resutt$r geatechnecal data and/or enVlrpnrnentaV5lte assessment Information to the SAN JOAQU IN COUNTY ENVI RONMENrAL HEALTH <br /> M PARTMENT as 5o pn as,t Is availatrle a nd at the same tiMe It is prpv]ded to me Of my repfe5entdthm, <br /> Accepted Bw � �1ssl To <br /> t , , � � LFnkad f*Po <br /> ll 1 e <br /> PE y Fee Rem <br /> 1 rdNumb4r <br /> f]cash <br /> llll I ❑Check ro LJ� CI Cunfrmaiion 41 Payment <br /> R2teh+¢d Ry <br /> ReV07/101Z1024 <br />