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PAYMENT <br /> San Joaquin County Environmental Health DepartmentRECEIVED <br /> Application Form MAY ° 6 2024 <br /> Facility Name ? L�1V1/lFtp N <br /> (/A L/ O/ v NALTFi DEP 7 AL <br /> Site Address ` City State ZIP <br /> //G/� al {� DC f4 26)- <br /> APN Supervisor District <br /> Type of Service Application for ❑Consuttation ❑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 1 ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> filling 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 2067 <br /> Pone y78 j2 � Phone /Email r/ <br /> C� 7 <br /> f�❑Billing Party acility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name e Last name /oa' If contractor,indicate type and license number <br /> 7" & <br /> Address , / City�^ //� State ZIP 20 <br /> PhonePhone Email Lfi/ <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 /> IL <br /> O <br /> Ej�e 21 7�/� one 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 applica ' and hat the ark to be performed will be done in accordan e with alllSSjAN JOAQUIN COUNTY/Ordinance Codes, <br /> APPLICANT'S IGNATURE:TATE and ERALIaws. ' } DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT is not the BILLING 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,hereby authorize the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepted By Assigned To iv Linked FA ID <br /> Iw <br /> Date SW Z PE # j COX Fee Z Record Number i1 a,400 <br /> I `T <br /> 5 <br />