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0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form FRZco3-cq- <br />Facility Name (7:-. ‘ 0 g i 4 1 ' S s 0 r6' Inlhe lc Fr- <br />Site Address City 5 0 [1/i(=-p-Wei./7,/6-".- - - /1Wv t i 7 0 olterov <br />State <br />(4-1.- <br />ZIP <br />070-6, <br />APN Supervisor District <br />Type of Service <br />Requested <br />,Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />IQ /6- <br />VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party gFacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />MOH <br />Last name If contractor, indicate type and license number <br />Address City <br />11 1/' fremutg,/ <br />State <br />(A— <br />ZIP <br />q f —u- <br />Phone <br />PO i 8 0 65?-2 <br />Phone Email <br />en on cik-i ell 6.1y /i)/,}1 e fLaal , 6071 <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 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: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />yr PROPERTY 1 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 that all site and/or project <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />laws. <br />ietC990' 0 / /7- Z/1,) DATE: <br />OWNER 0 OPERATOR / MANAGER O 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 />pii <br />ik.P it <br />Title eft <br />• .0 <br />at the above site address, here igterqie the <br />JOAQUIN COUNTY ENVIROOWNTJo_AL HEAL 2 A <br />4, eA1114;1QUIN , <br />"kit, 'TON L'OU IV <br />Accepted By <br />jel l C. Assigned To Linked FA ID 8 /2..4 rok 4' <br />Date <br />011281202s <br />PE 16o3 Fee $t/72 . coo $1.--1-r--- <br />Record Number <br />pp25e/54/ <br />/ <br />W'Cash (1.13--* Of 0 Check # <br />, <br />0 Confirmation # <br />Payment t <br />Received <br />Byeie70/ <br />. <br />Ha:- pat (5 cabk- 1(26 Rev 07/10/2024