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0 New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name N i ,.., <br />\ANr Ob \ g., rci\v \\A <br />Site Address 4 , .wic,h‘c\ s-- 7.0 „.53 State w\ ZIP <br />L.) Z <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation yr-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 />Jg1 Billing Party ,8„Facility Owner It Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name_ <br />TY'ff -cA <br />Last name . <br />C) V(\rieN\t_21-7 E.,6„, ,\\,„ ,„, it.\...0„.._\,.„ If contractor, indicate type and license number <br />State c.j c ZIP <br /> <br />Phone Email <br />ITT \ ‘fr\WC/12- \12 'C) (-'6 ft <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name PA <br />Address <br />1118C, <br />ir If contractor, indicate type and license niQb . 41 <br />City State ZIP I <br />JAN <br />Phone Phone Email 0 3 SAN Jo e <br />tiVvrIQUIN HEAL RoAia . CQ <br />0 ArchitePi0p7Air <br />Pr.111...! <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor <br />First Name . Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />N7). <br />Aft <br />E z) <br />025 <br />N <br />BILLING 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 prepare,yl this p lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL law <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR./jAANAGER 0 OTHER AUTHORIZED AGENT <br />Title <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />DATE: \J 2\ <br />Accepted By <br />'d c\ e. <br />Assig <br />CI <br />ned To <br />CAU•6iiCL. r\A . <br />Linked FA ID <br />FA00•2. <br />Date <br />tCP I 2.1 t 2c2_,-1 <br />P E Fee <br />A <br />Record Number <br />6R2,40(b-8_9 <br />PA. I 7,2 , C- Zit . '93&2 <br />Rev 06/12/2024 <br />PR P5n15S