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❑ New Facility 0 Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Zovbecue- Na.-l6ion <br /> Site Address City State ZIP <br /> 15 -338 S. H o-rla,n Rd. La.+hro CA q 5 330 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation VChange 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 <br /> illing Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Sa)l PSV M eA r>7` If contractor,indicate type and license number <br /> l Gl�(7O�6 Phone nlceY"e—b ts C) ,7 <br /> ❑Billing Party ❑Facility Owner Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> If contractor,indicate type and license number <br /> `�.��� 7 P.S�i C�e •aic��fvn �;� 9��b E <br /> Phone <br /> ee-v-Me-4ooh ►7.�i Cs�rn <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 t application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. / O I 1 11 1 a O 5 4��� <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT ���� <br /> etlw` O <br /> Title "i►�I 9 <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 addre � horize t �? <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRO� �dbl <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. O MF`.-04/54[ <br /> Accepted By S• 6a.I(LA3 l Assigned To L; n koxe c Linked FA ID S, <br /> Date, JE iw 0 Fee J Record Number <br /> ❑Cash Check# LIQ Confirmation# / /�j 7j f �/l� )-500 soqz <br /> Payment <br /> I �J c/ l I r Received By <br /> Rev 07/10/2024 <br /> ?R5r**30114+ <br />