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0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />0 Architect 0 Contractor <br />If contractor, indicate type and license number <br />( <br />0 72-3/-2-4 <br />Address <br />Phone Phone <br />Billing Party 0 Facilit, Ownei <br />First Name <br />Address <br />Phone Phone <br />cic.2., p c <br />ci t S <br />szt, <br />V.0 S <br />-1-Ck <br />:ontractor, in <br />e <br />Contracto <br />cate type and license number <br />0 Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner <br />First Name <br />ate <br />me, <br />PA Y <br /> j eCk Title t:41 <br />th all SAN JOAQUIN COUNTY Ordinance Codes, <br />me or my business as identified on this <br />If APPLICANT is not the BIWNG PARTY, proof of authorization to sign is required - <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, her ' aixtlItiri3e the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRQXVONTAL HE471,41 i-d:;:y; <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Pil <br />J0,4( I <br />, -16', : II , <br />nowledge that all site and/or project <br />-Q- <br />BILLING ACKNOWLEDGEMENT: I, the undersi, <br />specific ENVIRONMENTAL HEALTH DEPARTM1 <br />form. <br />I also certify that I have prepared this applicat <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATU <br />F44000.2-S31-1- <br />:0)..200 Z7-0 <br /> <br /> <br />0 New Facility 0 Existing Facility <br /> <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name A pl y A. p 1) )1 ,.- A bi DI/PCP - i 11. <br />Site Addresso93.4) iitu RD Roa D „City <br />rg enich 0)rilf <br />State <br />C13 '7522; t? 522 ) <br />APN Supervisor District <br />Type of Service <br />Requested <br />13 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />r -/-te,t (.1-• C.41 e tratl L,...c-- -11., ,...c j- c...., ,,,b".. (Ao . frv-v c 0-ii,1 tiy eR (An- 1 , <br />If mobile food truck or <br />pumper truck <br />Licetsi ilitii\slirber <br />4 .5..5 <br />VlNgc 9 1 142 I ai jv q2 48002 <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name...14 <br />fi tWiNDE <br />Last name <br />SVP16,1 <br />If contractor indicate type and license number <br />i 114 14 0 <br />Address—. <br />/ Strre /9g cifer ..&v .E <br />City <br />AlfiN 7 Eat <br />State <br />C A <br />zei 5.2 34 <br />Phone <br />920 ga git9 I <br />Phone <br />E <br />mail <br />YalwiockrAi 855 @ goial 1 -Cyr," <br />Accepted By Tve_ AssigVo i • Linked FA ID itIDP :ottp- il <br />Date PE Fee <br />t60 \ <br />s t (4.2 liecorcl Number. <br />H(t 1 - <br />Rev 06/12/2024