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D New Facility Ugr. Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />New S. L.:1 m Res-i-au.rant <br />Site Address <br />24317 e Prern 0 n't S'fre-e. t <br />City <br />S-1-9 GLI-Dki <br />State <br />A <br />ZIP <br />c152o5 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation Iii: Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Numbe VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor CI Architect <br />ril Billing Party Eir Facility Owner tit Facility Contact CI Property Owner 0 Contractor 0 Architect <br />First Name <br />2 envl r1.3 <br />Last name <br />Liarts9 <br />If contractor, indicate type and license number <br />Address <br />574-5 Ca riLb&n C ..1 r _SII-Dck-iii <br />City <br />-D . <br />State <br />CA <br />ZIP qs2ID <br />Phone Phone <br />20q- 04 - ct b CI <br />Email <br />shansilcxn 53344)1D -1-met; i.colyi <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 />El Billing Party CI Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and licenspOrn A <br />I viE) <br />ZIP REcpiu, Address City State <br />Phone Phone Email <br />JA iv 0 8 20; <br />RAN .. <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 />CI 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 <br />I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all sites , •D.— , • CO. <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business *MAIL .. 4444EN Tx <br />PA R TM <br />this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />laws \ <br />1 ..4 '4,0 P.' ' DATE:)( 0 1 / 0 17 (2'D 7,./g- - i <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 />it 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 />watitelY-0, <br />Assigned To IlivLuo Linked ,eA7.1.,D, _ A- -o-ootk k(-) <br />Date e..-- <br />I"11"--7 <br />PE <br />1(002 tria Fee Record Number <br />S R Q 500 7 64 <br />['Cash 0 Check 4 )(Confirmation 4 / 737 ?-8. 2_617-::: <br />P <br />R By <br />Rev 07/10/2024 <br />I T <br />5 <br />Wry <br />ENT <br />i3Z1tP2,1M 6