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D New Facility pi Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name . <br />- TA rio L 0 CO <br />Site Address I-7 4 S 1) A` A i ci n`.1 cg f() ci(4,1,rx State <br />Cil <br />ZIP <br />q56i5 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments A tec,t,, te.. ?lec,--y —e,vvv.ejLz_e-t) <br />License P <br />e <br />e Number If mobile food truck or <br />pumper truck <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 0 Facility Owner 0 Facility Contact ID Property Owner 0 Contractor 0 Architect <br />First Name , t <br />U ici,r <br />Last name If contractor, indicate type and license number <br />Addre s <br />sq 4-o City <br />ci..4)\ <br />State <br />C A <br />ZIP q s i is- <br />Phone <br />- 20q (3ZZ-13 IS <br />Phone Email , <br />.01c4 L-0 ,;'' <br />0 Billing Party 0 Facility Owner 0 Facility Contact D 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 FEDER , <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / 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 ..0cation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />LI.A.,?.--) < -) c_ <br />\i P" DATE: 0 -I - ,-/ -/ - 4--- _.) <br />OWNER 0 OPERATOR / MANAGER 0 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 />iily41 <br />Title -wzie at the above site address, ICr-.4 author' Ate0 <br />JOAQUIN COUNTY ENVIOJM • 4 LeEkLTH <br />—7, Jad 4 2025_ <br />WQ1i/A, <br />Accepted By <br />L.-----____ <br />Assigned To i 1 . N J <br />.84174 <br />Linked FA ID rif 0\fgeNCOutiv <br />Date 5., PE ( tto 0 Fee . I _ <br />$ 5 i (,:, . ci.ci_-: e7(p,....__. Record Number 'IT -4(.R P26 cDt coo--1- <br />0 Cash 0 Check # 0/Confirmation # lq ----(e6e6--q2-/ <br />Payment <br />Received By <br />Rev 07/10/2024 <br /> 115 0011-1