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I)3(. New Facility D Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name A i <br />ri (1 " i 1-0 c---> ( nrylochc) <br />Site Address <br />c rAk c (-oleo [ o si <br />Qty , <br />s frcig-nn <br />State ,, „ c A ZIP <br />q 5203 <br />APN Supervisor 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 VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />C11 05 <br />Last name " <br />()rn 06.1 Cl <br />If contractor, indicate type and license number <br />Address q 3 8 G o 't den 6-xt -I- r <br />City <br />5 -Forkion <br />, State <br />C. C i\ Z113'1520 ; <br />Phone Phone <br />tl <br />209685723 <br />Email <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 PAYM NT <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor <br />AUG 16 <br />0 Architect <br />2024 <br />First Name Last name If contractor, indicate type and license number <br />SAN JOAQUIN COUNTY <br />Address City State ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Phone Phone Email <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / BUSINESS <br />If APPLICANT is not the BILLING <br />AUTHORIZATION TO RELEASE <br />release of any and all results, <br />DEPARTMENT as soon as it <br />I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />this application d that the work to be performed will be done in accordance with all SAN JOAQUIN CO,JJlTY Ordinance Codes, <br />laws. c <br />1 — C' — i DATE: ji <br />OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />PARTY, proof of authorization to sign is required <br />INFORMATION: When applicable, I, the owner or operator of the property located <br />geotechnical data and/or environmental/site assessment information to the SAN <br />is available and at the same time it is provided to me or my representative. <br />Title <br />at the above site address, hereby authorize the <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />Accepted By <br />3e.Cc C• <br />Assigned To <br />t-.5 a i 0, 13CLit-eJe <br />Linked FA ID <br />Date (2)81U0124 PE t loo-3 Fee $1-i2.e a Record Number <br />AP240088c0 <br />Payment <br />Received By *ash 0 Check # 0 Confirmation # <br />Rev 07/10/2024 <br />N 25 oco 9' 3