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New Facility El Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form W25°02.11,0 <br />Facility Name <br />a t---e L ( r c-- Tea (C) <br />Site Address <br />-73 0 5 (,,/,:,--0 r 4 • 141 C71 <br />Citylt c. 0 c4-1-411 i <br />State <br />c/9 <br />ZIP <br />APN Supervisor District <br />Type of Service <br />Requested <br />ic Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner CI Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />0 ii7C7 9 ,. 3 <br />VIN <br />it / 6 - Pi Z K555506'51,7 <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner CI Contractor CI Architect <br />0 Billing Party 0 Facility Owner CI Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name ._,. Last name If contractor, indicate typeand license number <br />Address <br />/6)/3 C f/11.-C Al ( /1 0 C. ,--1 <br />City <br />c' <br />State c- ki ZIP 9 5:2/ <br />Phone <br />7,- 2. .--12/ (, <br />Phone Email <br />Ccere <br />t/ <br />CI Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor CI 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 I=1 Property Owner CI 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 owner, operator or authorized agent of same, acknowledge that all site and/or project <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FED AL laws. <br />//2/z-s—' APPLICANT'S SIGNATURE:( DATE: PC <br />CI PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT PA/114& <br />Title <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 'tete/Vett <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby author <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENsVIRrOvNijf4NT4 1.4EAUJ-1 <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />A o <br /> cV25 <br />Ac p e By A signed To , r3ccilk, Linked FA ID tiVVIRO—AV C°U NTY HE-44Th DE„,evrAL <br />Date 1 / ,24 2_ PE 110 0 Fee ,,. t -72_ fi--,--- Record_Nurnioer <br />NEN T <br />0 Cash 0 Check # <br />oa,ovr "LS Di-c-bl12., <br />66nfirmation # ( 9 ,3-42_,10 8 (2_, Payment <br />Received By gUe <br />Rev 07/10/2024