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12(New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name im KOmaine E n-Verp r -1 e <br />Site Address I <br />511A q-AJU C Wr)r DD5 "----UJ . <br />City <br />---oc_-.K:i-okk) <br />State ZIP A s <br />AP Supervisor District <br />Type of Service <br />Requested <br />application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />C VO ClaSS A <br />If mobile food truck or <br />pumper truck K1 0 <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />fif Billing Party E'Facility Owner 11(Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First pjafhe Last am If contractor, indicate type and license number <br />Addr ess City State ZIP <br />Phone <br />9-0\ 40Q-CI TC4 0 <br />Phone <br />Li <br />(-knell <br />L-togn,-4 <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owngr 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 <br />PASAArEkt <br />First Name Last name If contractor, indicRECEIycEnber <br />Address City State AUG V9 2024 <br />Phone Phone Email SAN JOAQUIN <br />ENVIRONMENTAL <br />COUNTY <br />mix,..TH DEPARTMENT. <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDE <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / 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 that all site and/or project <br />HEALTH DEP , •TMENT hou • . :es associated with this project or activity will be billed to me or my business as identified on this <br />. <br />. ; . . - .nd that e work to formed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />'•f,lf& <br />i <br />. <br />.1.-4--1,1------ DATE: y- /e - <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 ...-sc Assigned To LB Linked FA ID <br />Date <br />C1 - a Z1- R9 eq <br />PE Record Fee , 1? (.0 Number <br />RP2.400e)Gt <br />0 Cash 0 Check # Li confirmation # ty ( 21(11 13 <br />Payment <br />Received By <br />Rev 07/10/2024 (Ty‘ Acceirs- uk-fr•-41-°-"- <br />121214 no3S1