Laserfiche WebLink
State 6A '6152// <br />0 Billing Party <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facll"N g1ritnIL vnik <br />site rM8 Larrii Alt7M-rDiti v .51-CC-OZYn <br />APN Sup nor District <br />1 <br />, 0 Consultation 0 Change of Owner <br /> 0 Repairs or Remodel aOther <br />\2-Co.)•• <br />catkto <br />If mobile food truck or <br />pumper truck <br />Type of Service <br />Requested <br />Commer_lt) <br />CA—• <br />0 Application for <br />Operating Permit <br />o-uQr arne,t3f)1(3-n-crorn armar5-- <br />!cense Plate Number VIN <br />X Billing Party I 0 Facility Owner [Facility Contact 1 0 Property Owner 0 Contractor 0 Architect <br />Contact Types <br />required <br />o Billing Party 0 Facility Owner AFacifity Contact I 0 Prop <br />First Name kizx \44..a4 LastInre . <br /> /I MAT 41 I tn n3 <br />,---"N : Address Gin 1 ..)1cUln-l-n -briv-ed <br />Phone Phone , lEmall , <br />til.ABR,n51 l'untliv. (110b) (p_i±i -9M <br />S.Billing Party <br /> 0 Facility Owner <br />Fa me ' <br /> Las am <br />0 Contractor 0 Architect <br />If contractor, indicate type and license number <br />Stat <br />eCY4 <br />eAQ-bn <br />0 Contractor <br /> 0 Architect <br />If contractor, indicate type and license number <br />erty Owner <br />Tu2rr.9 <br /> <br />0 Property Owner 0 Facility Contact <br /> <br />162_1 <br />appd-i-1-, earn <br />r)v)...., <br />Addreisol Icuat -Dri <br />tiPzhon sio .1.4 Phone <br />Strpr <br />j—k--1135/1) <br />(.11;1;)2bl ...02q5 Phone I Email to.audarz1 <br />cke_04,balappe41:4 jury. <br />BIWNG ACKNOWLEDGEMENT: <br />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 charge.s associated with this project or activity will be billed to me or my business as identified on this <br />I also certify that I have pre red this applIca <br />and that the work to be performed will be done in accordance with all SAN AQUIN COUNTY Ordiviikeades, <br />form. <br />APPLICANT'S SIGNATURE:., <br />DATE: 63/11 g.O 2,n14 recrri T <br />Title <br />If APPLICANT Is not the BIWNG PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: <br />When applicable, I, the owner or operator of the property located at the above site addres <br />DEPARTMENT as soon as it Is available and at the same time <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENV1RONM <br />tIFA ThIV cof ENpillEiy- Y 124N <br />It N provided to me or my representative. <br />" l MEW <br />Assigned T <br />'2J1 gLci atyn n <br />Firnrire.„0 <br />Addr icLr Ein <br />0 Facility Owner <br />1 <br /> Email , 5onry- aruta2 es4b0-nappeti A- corn <br />0 Architect <br />07acillty Contact <br />'afro-rade) <br />0 Property Owner 0 Contractor <br />If contractor, indicate type and license number <br />State <br />0--rt <br />ZIP <br />Standards, STATE and FEDE aws. <br />0 PROPERTY / BUSINESS OWNER )'OPERATOR/ MANAGER 0 OTHER AUTHORIZED AGENT <br />MAR 12 2 <br />y authorize the 25 <br />-D514-21-- <br />Accepted By ottxt, Record Number <br />(SP,2500 9 / Fee <br />Oa-paid c1 oc 4F: igi-I-9025-- M-15 <br />R053 4/1.40 <br />Linked FA ID <br />PI+ 00 91/119