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U New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address <br />/ 75 / 0/, 74/pme ikve <br />APN <br />.C4y/fr i <br />fit--ton <br />State., ,____,4 ZIP <br />q5-20q- <br />Iiii-'10) <br />/Supervisor District <br />1 <br />Type of Service <br />Requested <br />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 Nam 4 . Last name , <br />g Ue <br />If contractor, indicate typeand license number <br />z, /A <br />Address <br />/ -75 / ki • 11 I pl 0 e. A- ve <br />City State„.)fi ZIP <br />Phone , <br />2oe7 so 83 7(/ <br />Phone Email . <br />.-,,D4'rriclIal Vg z-pri <br />0 Billing Party 0 Facility Owner — 0 Facility Contact 0 Property Owner CI 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 />0 Billing Party 0 Facility Owner CI 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 />BILLING ACKNOWLEDGEMENT: I, the unde <br />specific ENVIRONMENTAL HEALTH DEPA <br />form. <br />I also certify that I have prepared this ap't1ca <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:' r - <br />PAYMEN.r, <br />RECEitteribi <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addreikflazeby authorize <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRGaWIT14E2024 <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />"411 <br />Accepted By Assigri:61 To <br />' <br />.... --- <br />L <br /> inked FA ID taftRaiiiEZUNTY <br />NEIfirni DEpARTLAtiv <br />Date cl PE Fee Record Number <br />A (902110105 <br />T <br />Payment 0A5-76 <br />Received By 0 Cash 0 Check # lEfonfirmation # 1(64:69-10LE(f2R <br />ilOCROPERTY / BUSINESS OWNER 0 0 RATOR / MANAGER <br />gned operty or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />ourly charges associated with this project or activity will be billed to me or my business as identified on this <br />hat the work to be performed will be done in accordance with a SAN 1 AQUIN COUNTY Ordinance Codes, <br /> DATE: , t oq /41 202 . <br />I: OTHER AUTHORIZED AGENT <br />Title <br />If APPLICANT is not the BILLING PARTY, proof of aut orization to sign is required <br />Rev 07/10/2024 <br /> <br />p(zs 0009-5