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0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />o reyA. wv2o.-Iv- S -lcr) <br />Site Add ss <br />9-2.9 (\\or)-\) 1-kxm ..1\1 <br />City \....0 t -.. <br />(.1) 1 <br />State c_cx <br /> . <br />ZIP <br />q•.)62_1-1 2_ <br />APN Supervisor District <br />Type of Service <br />Requested <br />10 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />e <br /> <br />jj lAt44 f vtutl^- <br />Comments <br />.-----1-u--12---71k <br />If mobile food truck or . <br />er truck ----- z <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 O Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address cJ City State ZIP <br />Phone <br />q0---39 2.— 0 1:2)4 <br />Phone Email <br />Sk,pre me tyroAlstusAelc&oo-\-too I?. corn <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 />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor D Architect <br />a n ePtirititeb e r <br />EF? 0._ tlyr <br />First Name Last name If contractor, indicate type <br />Address City State ZIP CillEb <br />1014/ <br />Phone Phone Email SAW . <br />kA,,. <br />1 3 <br />jr, ti 2025 <br />'410i 11. <br />PA V V/ftlfVCr), <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDER , <br />APPLICANT'S SIGNATUR <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-RditifIgif f .4'sirAtill, .. t <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as i Atirritik this <br />' r <br />-... ..plication and that the work to be performed will be done in accordance wi hall S• N JOAQUIN COUNTY Ordinance Codes, <br />'Ns. \ <br />7 i DATE:/ <br />‘ 0 • 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />. <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 aylir, (.._.--------- n , <br />,A,ned To , <br />At o'.-4A,(A4A4)- KA) <br />Link_e.d.FA ID <br />f—fi OP 6-8 R i <br />Date <br />I 1 7) 2 s' <br />PE • <br />i(0 0 2. Fee <br />I 1 a__ <br />Record Number ' -,. <br />--,e sg25exp-711 . <br />0 Cash 0 Check # *Confirmation # IT-11-3OLI" 2g 7 7 :: B\ Reved cei B <br />Rev 07/10/2024 <br /> <br />VR0521151