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D New Facility /Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form ?p,0941-N2.3 <br />Facility Name _ Ros.e Te a_ L otAn e_ <br />-------- 7 <br />5(O34 <br />Site Address City <br />N. 'Perskin Ave. s-i-Oc._ 0-bin . <br />State <br />CA <br />ZIP <br />6/5 P-04 <br />APN <br />t'og.. i 50- IQ <br />Supervisor District <br />a <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />O Consultation Zange 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 />'Billing Party IR 'Facility Owner 0 Facility Contact 0 Property Owner D Contractor 0 Architect <br />First Name Tw. <br />aw-a_ act, Last name . • <br />11\1 GCI- ei4 <br />If contractor, indicate type and license number <br />Address g6 4 R pkttfi t <br />(\WOW Wati.- <br />City E- t IL erove State cpc ZIP 1 f6 2.6f <br />Phone .34 gq 2. 512 <br />Phone <br />g 6 <br />Email rte , Stb dcf --o fri cjvvIctei( , 0)111 <br />0 Billing Party 0 Facility Owner 52'Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Na Last name If contractor, indicate type and license number <br />Addr s City \ State ZIP <br />P •ne ••••2 Ern • 'I <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor <br />PAYMENT <br />D Architect <br />First Name Last name If contractor, RE indicat ber CEIVEDn <br />Address City State NOV zii 5 2024 <br />Phone Phone Email SAN JOAQUIN <br />INV <br />COUNTy. <br />RONMENTAL - <br />DEPARTragri____ <br />all site and/or project <br />as identified on this <br />Ordinance Codes, <br />HEALTH <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 />40PERTY / 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 <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business <br />this application and t at he work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br />laws. <br />DATE: A( /(r (2024 <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 Assigned 3e44 C. <br />To <br />Lydia B. <br />Linked FA ID <br />FA 00 a 5 3(05 <br />Date <br />11 -I5 -Q4- <br />PE <br />1 (poa Fee <br />11 \ 7 Q <br />Record Number <br />SRa4.00(p45 <br />0 Cash 0 Check #:firmation # ) 1 ks-66IcL( Payment <br />Received By <br />Rev 07/10/2024