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El New Facility a4xisting Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name _Th e, illiL <br />Site Address , , „._ <br />1 .04 N. S a c at m e ri to S. . City i <br />1..._ o ai State c /9 ZIP i 5240 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation /Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner El Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />ISKilling Party El/Facility Owner St<acility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Nam , Last name / If contractor, indicate type and license number <br />Address Citylta ( k State( 4 ZIP <br />Phone <br />--,7_0(i--Z Y-676 <br />g6( <br />Phone Email/ <br />t iro /12eZ is J <br /> <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 />First Name Last name If contractor, indicate eitlikAirn b er <br />tvECEivert <br />Address City State <br />.4p 1-) <br />ZIP ga <br />n <br />u 3 2025 Phone Phone Email ' <br />SAN Jo AQuim , <br />' ' L•OLINTy ENOR0NmF H <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />, - <br />0 PROPERTY / BUSIN-ESLOAblE, <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 />TtfcRap • I, the undersigned property or business owner, operator or authorized agent of same, acknowledge A or project <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identi MicTon this <br />this appli - ,,n and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />laws. <br />DATE: <br /> <br />—..milidr11111011 <br />......... .i_ 7.,_S <br />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 />S - .?)Gt.qu.) 0—k r- <br />Assigned To Linked , <br />- - • R U I -7._ FA ID FA Cn 0 0 -5 3 9 <br />Date 04 -03-5 PE <br />1 (s 02 Fee ,it I 702. °%'' Record Number sizas009 -71. <br />0 Cash 0 Check # 'Confirmation # 6 2 (QN, 20(0 Payment <br />Received By <br />Rev 07/10/2024 <br /> <br />\gb t0c-/Ao