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San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name George Perry and Sons, Inc , (dba Perry's Market) <br /> Site Address City State ZIP <br /> 13881 S Highway 99 Frontage IVlanteca CA 95336 <br /> APN Supervisor District <br /> Type of Service I(Application for [$Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party Facility Owner Facility Contact Property Owner ❑Contractor ❑Architect <br /> required 7 1 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Ran Perry Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> PO Box 2588 Manteca CA 95336 <br /> Phone Phone Email <br /> 209-249-2400 ronp7@mac.com <br /> ❑Billing Party ❑facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑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 CUUN IY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. h <br /> APPLICANT'S SIGNATURE: DATE: 10-11-24 <br /> Rq <br /> M PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT •aEC I�N�+ <br /> Title //��yy <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 00, / �O <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,here uthori th�7 <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTA 0� <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. N NV Q4// <br /> Accepted By Assigned To Linked FA ID r;�, r� <br /> (yl �, r <br /> Date 0 112=41PE C 2. Fee 1 Record Number <br /> 16 f • <br /> lu 2 <br /> �21E.; Is <br />