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U New Facility Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Papa s $ 1&'n 4,5 Site Address 7 v 3 C., pi. rity ' - tvi it_ State .A._ L.- ri ZIP Klge,3 2 APN Supervisor District Type of Service Requested 0 Application for Operating Permit 0 Consultation g Change of Owner 0 Repairs or Remodel 0 Other Comments If mobile food truck or pumper truck License Plate Ntirn_te, _ ,..4 H v et-i") VIN isc/T 69x /(vo A-4m 6) .9/1`/-1 Contact Types required 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect yfBilling Party 'Facility Owner .Facility Contact O Property Owner 0 Contractor 0 Architect .,. First Firm' iziv t_o Last name _ M Of ti Wilei If contractor, indicate type and license number Acicires sl /0 Fa' e '1 rs-1 l f-- City 6 a If -- Stati404 ZIP if3sco3--z Phone _ , -yyt u7StgicrDS- Phone Femall . Jre hrnosque(lai ill mueeleor-flc,i pcmeA- 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner O Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor Firr P7141T First Name Last name If contractor, indicate type an_i_lifirrar API? 1 Address City State SAN JOAQUIN 7 ZIP i 1 2025 Phone Phone Email ENViRD HEALTP COLMirt, D A/MeVrAl. . r EPARTa . — BILLING ACKNOWLEDGEMENT: specific ENVIRONMENTAL form. I also certify that I have prepared Standards, STATE and FEDERAr\ B 0 PROPERTY! BUSINESS If APPLICANT is not the BILLING AUTHORIZATION TO RELEASE release of any and all results, DEPARTMENT as soon as it APPLICANT'S SIGNATUE: I, the undersigned property or business owner, operator HEALTH DEPARTMENT hourly charges associated with this this application and that the work to be performed N 5_,..„}__ or authorized agent of same, acknowledge that all site and/or project project or activity will be billed to me or my business as identified on this , be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, ..: f q-/.7.-z 5 OWNER 0 OPERATOR / MANAGER O•OTHER AUTHORIZED AGENT PARTY, proof of authorization to sign is required INFORMATION: When applicable, I, the owner or operator of the property located geotechnical data and/or environmental/site assessment information to the SAN is available and at the same time it is provided to me or my representative. Title at the above site address, hereby authorize the JOAQUIN COUNTY ENVIRONMENTAL HEALTH Accepted By C. Assigned To Fro-0 Ci S c_o 12- - Linked FA ID F-A cbcb 2-i q Date PE Fe? 00 Record Number SR25(2)1 (2) 1 3 0 Cash 0 Check # /Confirmation # 2.O0 1 g t, 64,7 Payment Received By Rev 07/10/2024 NOSLi T150