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P2500 n <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />fOr t I ler/01 1"00/1— O• pi o,r; 2 • <br />Site Address <br />/2-9 01A/Oly City 546c6an <br />State 7 <br />uot <br />ZIP <br />T5ZOS <br />APN Supervisor District <br />Type of Service <br />Requested <br />ID Application for <br />Operating Permit <br />ti 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 />EiVV7_7(A <br />VIN <br />(,G, 11303 <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />04 Billing Party )(p Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name nr <br />PI <br />, <br />(NCI /9 e ) <br />Last name,, r <br />itj Old- in_ C- Z <br />_ <br />If contractor, indicate type and license number <br />Address i - z City 5 foa ton State ( <br />\- R <br />ZIP 7Bcos Phone <br />249-S07-33n- 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 />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 />_ <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 FEDERAL law <br />APPLICANT'S SIGNATURE: <br />‘A <br />Ct sit v-k DATE: 0 —D 2 <br />LI PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER D OTHER AUTHORIZED AGENT <br />YA/i Title <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />ReCgi AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize e <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAd*Th <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />u 7 20 <br />Accepted By <br />7 c c C. <br />Assigned To <br />cuimktic-L K ( - <br />PE , chi <br />rii <br />- <br />Linked FA ID lieZilli- wvfilock/vw coim o moir PAt. A/ Date „ <br />CA (Dt41 •2-Cb24 ' ,e, W I <br />Fee <br />4 <br />- 4b6.00 1 qv 1° --- . Record Number -'1T74fEA 13P2x/ 02% 443- <br />pa:1024 cagu- v,(Y1 <br />5-51 <br />3