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C New Facility liExisting Facility San Joaquin County Environmental Health Department Application Form Facility Name Q -'-- Site Address \\ A , C. W , ..,ILLVCArkeirtb City Lc State ZI P q50140 APN Supervisor District Type of Service Requested C2<plication for Operating Permit 0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other Comments . RtrAOCtel ... Plan checK If mobile food truck or pumper truck License Plate Number VIN Contact Types required 0 Billing Party ...,' 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect IYBilling Party ErFacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name W Last name %— If contractor, indicate type and license number . Address \ Ct,k% V..45s,e_'Ma\A-c Do \ut -)ctli-- State CA ZIP P5(c,a erne ItP-70-&S-3(40 Phone • 1 Email (*en a-M \IC Mat\ ' Carr ID Billing Party IS1.4cility Owner 0 Facility Contact ''] Property Owner 0 Contractor 0 Architect First Nal WAY\OWte) kr‘ 11 — If contractor, indicate type and license number Last Tee:AA ,..._5u Address , ..... \ta\i\--k-:^eY \\C( City ty CHCA 0- State ,,,,‘ c,\-r- ZIP aSgLto pzct —P51--k— Phone 55 i 6 ..r•nail ... ‘c 1 or.ANt)6 ensi-N,oa\Lco(y) 0 Billing Party 0 Facility Owner 0 Facility Contact 0roperty Owner 0 Contractor 0 Architect and ligkrimpber Peer 414 First Name Last name If contractor, indicate type Address City State ZIP Phone Phone Email , De e 2 6 , N 01.1 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge'r form. Standards, STATE and FEDERAL laws. I also certify that I have prepared this applicat the wo APPLICANT'S SIGNATURE: DATE: specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as i4 i4ie k rv IE to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, PPo /91 OPERATOR! MANAGER 0 PROPERTY / BUSINESS OWNER 0 OTHER AUTHORIZED AGENT CRTetilYe-Coru`r If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Accepted By V1( 0 escc, Assigned To A . r1.4.4, t'......- Linked FA ID 0_6,0 -) 1 1 ,......2.3 Date PE Fees 51(9 Record Numberiti /-_,,3 40 1 41.1 0 Cash 0 Check # /Confirmation # P3 1_5-'0Z Payment Received By PQ0It00123 Rev 07/10/2024