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( -7 1 ( <br /> 0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name .---7--- <br />l 0141 / I C.; <br />Site Address <br />---) i (1) CO .. ( ii 6 /4 ef-OAy <br />City ., Statu 711,), (-_,) <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Peimit <br />0 Consultation hange of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />L z . ,Z -rc k ir <br />If mobile food truck or <br />pumper truck <br />License Plat i 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 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name,- <br />J-- S S. q <br />Last nar_ _Lel - <br />1 6i cif6 S <br />If contractor, indicate type and license number <br />Address /-) <br />, al Cl Oc-t c) ii, C b (Al <br />C <br />- ,i) oic ii c/0( <br />State <br />Cil <br />ZIP <br />Phone <br />11 2 -%c <br />Phone Email <br />I +V:.,i'lric '?n4/, ca 01 <br />o 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 />0 Billing Party 0 Facility Owner <br />- <br />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 />BIW NG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <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 />Standards, STATE and FEDERAL laws. <br />DATE: -21 i ()PS P APPLICANT'S SIGNATURE:AI, <br />'-ir 10 M <br />O BUSINESS OWNER tLOPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Arett f col c_I-1c I <br />/1/k PROPERTY/ <br />Title <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required paz <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby fh9ni <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIROCIIKIIRIT HEALTH 4 (14 <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Accepted By , <br />C 1 a vrt,i -6-e-e, <br />Assigned To <br />i ilei rte -C <br />tl <br /> <br />Linked.FA ID o6p16)vr4L - ( 2 <br /> <br />4-14_ Co 2 (.., 3 <br />Date <br />7- - '10 2, ,-- <br />PE <br />/t 0 2- <br />Fee <br />( 79- '2-- ,C I-4' $‘.9());----- <br />Record Number <br />ScZ2-50Q)8(03 <br />0 Cash 0 Check U 0 Confirmation 41 / (.7 6, ‘74-Cig2-e-'2 i <br />Payment <br />Received By tti1/476/' <br />7- <br />Rev 07/10/2024