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New Facility Af Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name a) we, .IV ()/EN ottr,... D e.. Li <br />Site Address City 6 6'-. w PAY- )- - ( 0 4 ff -st cx-1-3-kj State c A ZIP <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation <br />‘ <br />1)3Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />rfl.".114t <br />itrolt,,n <br />If mobile food truck or <br />pumper truck <br />— LicePise—Plate umber 1 VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />ABilling Party 124,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 <br />-:-..--- / 3 6 o 0 d Rio c_i /1 <br />City <br />C_o (IC 0 r-c), <br />State cg ZIP <br />Phone <br />6- 1 I __(,02_24 ut <br />Phone Email , <br />EitAc11),_ I nues1;77 en 10 61.."-to i - Cori 7 <br />El Billing Party 0 Facility Owner ,Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name ReiAlf pi Last name <br /># ovvm If contractor, indicate type and license number <br />--0--m /6/4 ) Address Z(....) 4-9 Ckt <br />y7 <br />City65,31 652,0) State c h ZIP 9952 <br />Phone <br />‘o 62 92 5 4-35 <br />Phone Email vain c.t) rrajoty 60 ,,.. 0 j/ktelli— 6-rrt <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor <br />If contractor, indicate 11E6 . PAYMNT <br />0 Architect <br />s mimber <br />ED First Name Last name <br />Address City State <br />SEP <br />ZIP <br />1 8 2024 <br />Phone Phone Email <br />SAN JDAQUIN <br />ENVIRONMENTAL <br />COUNTY <br />- <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 />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, acknowled e a al iteNgtgRirct <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />li ....., <br />lc.. t.1 U ES2.--..,.--,.- DATE: (".' Cl / AR/ 20 <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 />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 HEALLH <br />Accepted By Assigned To (..r ,4c t.,ftiz..._ LrAdIA_I D2 <br />M. .z 2 ILI <br />Date l l..4tvz 2..s.t PE 1 60 2...., Fee <br />k7 b2_, <br />1 <br />os jdev .--Yc <br />ecord Number --'5A S R2_400) 5CD 3 <br />0 Cash 0 Check # firCorTifirmation # p\ f ir 1,k, ,c73 Payment <br /> . Received By <br />Rev 07/10/2024 os3 c1661 <br />Application Form