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44t\ <br />Site Address <br />APN <br />OPedlleitt Contact Types <br />repotted <br />Heine Party I Faelfayeaorea et FacAty Contact 1:11 Prepare; Cramer 0 Contractor <br />0.4 tki}..1.4‘ 2*'45134 <br />Swerved ototrict <br />113 nPoket'oe rm 0 <br />oceettirtc Pura <br />0 Change of-Osorer IS Repairs or Fahoodel 0 Otha <br />I Leeree Plate Number VIN <br />tat nitaName <br />Typa el Sconce <br />Perattegen <br />Co anis <br />It mobile food deck or <br />pumper tnek <br />15 Architect 0 Contractor <br />I zip State <br />Loma P,ICAE <br />rlddrell ZIP City <br />Mod Party <br />1 trra, <br />C. <br />o FadlIty Owner l 0;deafly Car-WI ArcIsaed 0 Property New 0 Contractor <br />liiFai-Illty Owner 12 22ire Party <br />[ma Phone <br />, Olt tacky Contact <br />ast name <br />NAVAR._ <br />I C Property Crane, 0 Contractor 0 &drifted <br />if nonmetal.. in ale type sod kerne number <br />Fast Name <br />I <br />L*St name <br />4Asyle, Address <br />050 MP-194`ferr ‘)C.‘ <br />nom " Phone <br />t,10) tic -Arra <br />If =Pacer, mdiarle type and Pante RUMOR( <br />Address City <br />cl Br line Part —I a milky Owilie <br />test Name <br />0 PaolityCentaet I D Property Owner <br />Last name It cortlIattOr Indicate rya, and Deems number <br />Accepted fly <br />Da <br />I Urked fa ID F7r DP 2.4 <br />Peeve mantairS V.25040.395 <br />San Joaquin County Environmental Health Department <br />Application Form <br />PILING AC2IPDVAPOOtalltraT, L Pin undcenned preperty or buSlneta owner, *avatar s, autherieed IgiEet on same, aranantadge that all site and/or protect <br />speafir ISPARLYYMENTAL nr.ALTI1 OBPAIITAtENI hourly charms suodated Wilt this prOpeet on a ctAlty voll be anion to inner my besihess as Identified Cr 105 <br />form, <br />I a/so redly that I hare prepared dos amok:Won tad that Vie wort to be performed will he done In accordance telth all SM1 JOAQUIN CG.11/11Iihtlinance Lodes. <br />Standards, Start and FFIXNAL <br />APPI WANT'S SIqNAtt.NIE• pATT,%'J 111-L5 <br />IVROPEICY ( BUSINESS CANER iJ 00ERATCA / MAMndAEP U 01111.15 'WTI tORIZED Adel NT <br />IPPPLKANT Is not the BILLING Man% oroefolialhcoaaiiortto stn 0 redurPd <br />AUTHOREZAVON TO IttLiuSt INFORMATION: Wane applicable, I, the owner or operator of he properly located at the above sae address, hereby authorize the <br />release of tor and all ratuaa,taataeac.cal data andlor erwircelmentaVOte assessment informer:en to the SAN 1COVILIIN COUNTY ENviRCINPAENTAL HEALTH <br />DEPARTMENT as soon es 11 Is ayaliohle and at the same time it It presided le one or my rapresentattre. <br />-pro <br />PAYMENT RECEIVED <br />JAN 1? 2025 sA <br />N JOA QU/N COUNTY EN V/R <br />ONMEN TA L HEALTH <br />DEPA R TMENT <br />?jL_ qtr(72,C0 */5'-/S-773F23 <br />arin-