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San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />El Cejas Meat Market, Ilc <br />Site Address <br />4416 E Hildreth Ln <br />City <br />Stockton <br />State <br />CA <br />ZIP <br />95212 <br />APN Supervisor District <br />Type of Service <br />Requested <br />lerpplication for <br />0 erating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel El Other <br />Comments <br />Type of Business: Meat Market <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />A Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Xilling Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name , <br />Genesis <br />Last name <br />Soto <br />If contractor, indicate type and license number <br />Add rePO Box 54 1-tnru2 • 95o1 "or°, Dd P !CAC< City <br />French amp <br />State State <br />CA ZIP 95231 9s2ja <br />Phoile <br />209.400.3664 <br />Phone Email <br />genesis@cejasmicheladas corn <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 numbe <br />Address City State <br />() I <br />t <br />11 <br />\ /) ( \W A <br />- <br />1.1)Z1), <br />Phone Phone Email <br />v <br />CI Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractoal i v b ArNitect <br />First Name Last name If contractor, indicateRANMENTmber <br />State REGFEIVED Address City <br />Phone Phone Email <br />CAM ICIACII <br />Y 1 3 2024 <br />11A1 MINTY <br />ONMENTAI <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowlecH attAllotpArRitfgerffect <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 prepared this appl cation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL lavr. <br />APPLICANT'S SIGNATURE: DATE: 6//3/.7y• <br />0 PROPERTY / BUSINESS OWNER <br /> <br />0 OPERATOR / MANAGER 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 />Accepted By .F-- ,_\_, . . .-7 Assigned To —, <br />r <br />p_itA i .z._ Linked FA ID <br />Record Number <br />CI t 2......„ <br />Date PE Fee s ;_l I Ni tilk. a ct oi d Otv <br />/ I <br />i....1„ 1 <br />7 1 <br />--ftfl1' pc -VLd 13 ;172(-/- -A-02-