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ID New Facility l2 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facilityme / <br />//M.. <br />45 <br /> 5 XV lifi f/t-/C/''' /-a/diff/Gf 1 <br />Site Address <br />/ ,d274K I-49-'71 P ciA/ ,4 /1. <br />City <br />VriefriG ri/ <br />S <br />t?-7te <br />ZIP <br />APN Supervisorr <br />I <br /> District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />/4 FF C 0 n S tilleJ1011 (A) ) <br />If mobile food truck or <br />pumper trL .1_2_Z_2/._ <br />License Plate Number i../ 96 <-5-0 VIN <br />73 6 <br />Contact Types <br />required <br />cBilling Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />;,,Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />/I/ i c i7A-11 A <br />Fl Name,La <br />13 /14/-4,_f/t-r/ <br />siL7-.. me/ / <br />ieN// p-1 /4 /,5/f/ <br />If contractor, indicate type and license number <br />Address T ity„...., <br />..5kCy&a/1/ <br />Staty 4. ZIP <br />Y_ro2 <br />Phone <br />‘, 5 O. Xi6CoOS <br />/oeir Rirri i 'I/jk. S /9 g-- <br />Phone / Email <br />fiii hi///,,ym/e fhtik, . Ce;,-, / <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 CI Contractor 0 Architect <br />First Name Last name If contractor, indicate type and liPool ber k-4, <br />Address City State ZIP COI, r <br />Sep Fo <br />Phone Phone Email <br />Pito <br />//202 `9 /101, <br />4 <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FED <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, acknowledge thatSailifityek:4471),, <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as iden4 *44his <br />Al. <br />t i 47 cati.:, • e • . the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />A .ti Aillr#, .- e---/ K DATE: r 7-, - .2 <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 HEALTH <br />Accepted By ,.--- Aissnl llsauNtAch_ tr.liA_IN.evtzl Linked FA ID <br />Date 9 \ I LI 2...Lf <br />PE <br />110 0 3 Fee lqJ <br />Record Number <br />Ap24010/8 <br />0 Cash Check # OW' 0 Confirmation # <br />Payment <br />Received By <br />Rev 07/10/2024 <br />00S.L10