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0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />PAYME <br />First Name Last name If contractor, indicate type and licensilEtrEivi <br />Address City State ZIP <br />AUG 29 2 <br />Phone Phone Email <br />SAN JOAQUIN C <br />ckraiormIRA=h1 <br />0 PROPERTY / BUSINESS OWNER <br /> <br />0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <br /> <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 />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site ati cP;'fic <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 />.8/2-q)2k4 <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />ED <br />024 <br />UNTY <br />TAL <br />RTMENT <br />New Facility <br /> <br />0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name i \ t 0 IN) 6 ) ,.-A -..i-1(2t_M <br />Site Address 1-30 S cod i. for - c.fre.j <br />C-Ck Li covvi C_A 'FC al' li Mt dc weksh <br />City c+vcktriy.1 State cA ZIP GI ca 0 3 <br />APN Supervitor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />Li N \I i---i 561 ci <br />VIN <br />ç.4,) 4C- k` 4 F' i 0,QT 35R <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />1 <br />A Billing Party x Facility Owner 0 Facility Contact 0 Proper y Owner 0 Contractor 0 Architect <br />First Name . <br />riDeQ p 1 ka <br />LaAna <br />Y <br />me <br />ei <br />If contractor, indicate type and license number <br />Address <br />0214 9 giVe)? t•Oi Ho tA) Av,z_ <br />City State ZIP <br />Phone <br />SH 1- C-e . 4-g6 6 <br />Phone Email <br />'04-')`^ki d 0, dkataPi @ fityv.cki I • orni <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />Accepted By.,.. <br />Jek-V C. <br />Assigned To <br />L9diCA (6 ' <br />Linked FA ID <br />Date „ <br />(DEA V i 20 <br />PE <br /> Ik0 kU3 <br />Fee <br />$117.coo <br />Record Numbe r <br />kVe2__ 986 <br />0 Cash 0 Check # )(Confirmation #- 22 / 0 <br />PBaeycemiyeendt By <br />Rev 07/10/2024