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form. <br />I also certify that I have prepared tJi-pp1catiayI and that the work to <br />Standards, STATE and FEDERAL la <br />APPLICANT'S SIGNATURE: <br />performed will be done in accordance with II SAN OAQUIN COUNTY Ordinance Codes, <br />DATE: <br />New Facility <br /> <br />0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />emco 4 e,(4(ACAL t <br />Site Address <br />111(415 KI L O`A(CV-' b.gC5 12-9 <br />City <br />LO 0( <br />State <br />e,,Pc <br />ZIP <br />9 •C q 0 <br />APN Supervisor District <br />Type of Service <br />Requested <br />.Application for <br />Operating Permit <br />0 Consultation 0 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 />Rgilling Party ,Facility Owner ,p'racility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />Pitrkit 1 up <br />Last name <br />CQviA`f ue: <br />If contractor, indicate type and license number <br />Address <br />1;042- \ /) i -1--kwiltke-12__ p_c, City <br />Lo D ( <br />State <br />C"- <br />ZIP <br />q6-12-4/ b <br />(Phone, <br />la0C( ) 5r4"1- q r/e i9 <br />Phone Email <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 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <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 />0 PROPERTY/BUSINESS OWNER <br /> <br />0 OPERATOR / MANAGER <br /> <br />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 />Accep.tgd By <br />,je-a C. <br />Assigned To <br />"Francisco 12 <br />Linked FA ID <br />Date <br />Kbi 2.8 Z02-(1 <br />PE , ,- <br />11 i'S .00 <br />RivNzumlbeo,/ 2// <br />Rev 06/12/2024 <br />-NILloog )3