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0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name ?._ EZ.o Tz irfik7.,a) .. Site Address <br />G i 5/ LaiilzE A -ILE <br />City <br />moi)Z -S To State <br />CA ZIP 9S- Tc.-/ APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />)(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 /> 4 2.41 , Li 2_i S .77,9ssosi6. (75725 1 <br />Contact Types <br />required <br />0 Billing Party ,Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name _ <br />2 .0 S <br />Last name 4_ojuzz ____ If contractor, indicate type and license number C <br />Address 5A.AAE City State ZIP <br />Phone <br />.29 ,1-921-5317 <br />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 />PAYMENT andlitENED <br />RE <br />First Name Last name If contractor, indicate type <br />Address City State ZIP <br />AUG 21 2024 <br />Phone Phone Email <br />SAN JOAQUIN COUNTY <br />ENV1RON ENTAL <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />)4ROPERTY / 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 thatiBAltilinWOME <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 applicati an) tha ork to e pe Med will be done in accordance with all SAN JOAQUIN 0 NTY Ordinance Codes, <br />laws. ,,_ 2) ,i_i <br />DATE: <br />/ _27_ i <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 />Title <br />at the above site address, hereby authorize the <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />Accepted By ,.. <br />C • 4/1/itif) <br />1 <br />C <br />Assigned To ,.ki ene 0 <br />• <br />Linked FA ID <br />Date ) ... 2 .7 ,21.11 PE /‘(&5 <br />Fee/ <br />7z R , _ 8 <br />0 Cash 0 Check # 0 Confirmation # <br />Payment <br />Received By <br />Rev 07/10/2024