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El New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name , <br />/ <br />') )Ck?Vei 6,6 <br />Site Address ) i. ,- ; <br />c i 1 <br />State c <br />UN- <br />ZIP <br />ciS—U7- 3 <br />APN Supervisor Disthct <br />Type of Service <br />Requested <br />E(Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />pic\,2J i 0 ,-AS (ij 12°-1-4' 4C CI ---QT781k h 0 f A00, tar -H (N, .S0— c-3,_,,,\_447 <br />If mobile food truck or <br />pumper truck <br />License Plate Number 1 i AA 5.0 (0 O VIN lcci G-100 19 <br />?II 51-01C <br />Contact Types <br />required <br />0 Billing Party <br />/ <br />0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Cif Billing Party d Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name ...ri i <br />14— ti,VA(O t l <br />Last name , <br />AA- C C) ( Ol6bi <br />If contractor, indicate type and license number <br />Address 1 1 vir <br />Phone <br /> <br />City ../z, i State n ZIP <br />e"-{1471 Phone <br />(MA U --13& <br />x t <br />Email i <br />kitkAkeli4701A.14 01 ANA' ' Lb V‘k- <br />0 Billing Party Li 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 Li Facility Owner 0 Facility Contact 0 Property Owner El 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 />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 />1114ROPERTY / 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 DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />this application and that th rk to erforme e <br />laws. <br />done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />DATE: !Ayw <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 />1T C <br />Title <br /> <br />APR y I <br />at the above site addresaiwe authofie4V5 <br /> <br />JOAQUIN COUNTY ENVIRON Q OLT H <br /> <br />H 0/44%,..' COu <br />PAZ,Zrk. <br />Accepter <br />11-CIA.e5C 0 <br />Assigned To Linked FA ID <br />M000C0'452 <br /> <br />Date <br />Q3411(rA25 <br />PE <br />(aQ) 3 F e 112 .0,2) -1-Q1—v- <br />Record Number <br />Sk12_ 0)10 I I <br />0 Cash 0 Check # Illonfirmation # 2 DO IS 2 1 <br />Payment 4,v77( <br />Received By <br />Rev 07/10/2024 <br /> <br />NO50'10111-