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TcL <br />/A4 <br />(ined2611-1.- 4 D D 2 0 2024 <br />u/v7. <br />0 Air y <br />JUL 17 <br />'41^/,/0,1 <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Nam "- <br />e t-DCM/ k ik\) 01 C \•Vak VI -0 <br />Site Address 5 s 61,e* ith A <br />/11 <br />A <br /> 11 <br />ut. 1 j.+ <br /> <br />Cit. <br />AACkAleCOk <br />StateA c I ' 5 3(0 <br />APN Supervisor .istrict <br />Type of Service <br />Requested <br />3;11/ r. Application for <br />Operating Permit <br />D Consultation C Change of Owner 0 Repairs or Remodel O 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 ID Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />„C2 Billing Party .Facility Owner ,„ii Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />c)()1/4NA Aro._ <br />renxc If contractor, indicate type and license number <br />Address 1(b5 cl...fikrx.,,, A4z, k ,t, 1 <br />i <br />ciA6 <br /> nAel-c‘ <br />stp x <br />6 <br />Z•Pg s 33 G <br />f <br />»..d .. <br />Ernail <br /> .c,IN <br />. vior,cois, 4 <br />0 Billing Party C ,Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license numbe /1 <br />Address City State Z!P 4, V <br />Phone Phone Email <br />- V C <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 owrer, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated v, this project or activity will be billed to me or my business as identified on this <br />form. <br />Standards, STATE and FEDERAL <br />DATE: 01 J tauD-t-I APPLICANT'S SIGNATURE: <br />I also certify that I have prepared thi plication and <br />la. <br />/p,e th w' rk t be performed will be done in accordance ith all S N :0AQUIN COUNTY Ordinance Codes, <br />.S.,PROERTY / BUSINESS OWNER <br /> <br />7..", OPERATOR / MANAGER <br /> OTHER AUTHORIZED AGENT <br />• <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 a: the same time it is provided to me or my representative. <br />Accepted By .,.., Assigned To v .--- <br />. <br />Li FA ID 1 ysv <br />Date ' . -?-- /212y PE , 1 • 6 ---, 0 Fee, i 6 intbien, . I 36 .,....r.zNzzi.v,ic <br />"v1 7- _