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0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name J <br />Pia' ri 5 CO5 - 7 Z P/ ,6 47 -771 <br />Site Address 1 g ' <br />17 f 7 s , 0 a /z) n <br />City <br />---7--0(4---re A/ <br />State <br />CA/ - <br />ZIP <br />q.520 6 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />tZonsultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />e,- oorivok in Tex on( k <br />If mobile food truck or <br />pumper truck <br />License Plate umber <br />96 q 7/E2 <br />VIN <br />/G-c32<2 T332/.052 <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact Vitroperty Owner 0 Contractor 0 Architect <br />A Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name, <br />Po b erth <br />Last name , <br />MOrarle5 <br />If contractor, indicate type and license number <br />c,57/11/ <br />Address r <br />/5 <br />Phone <br />City <br />5 -7 --a.<-7-zwi <br />State <br />'/_;1 <br />ZIP <br />q52o 6 1(2 5/91/7 .57 4- <br />209 6/2- 956, <br />Phone Email <br />on)vvrw/e5 if$ ,Og 01,7/ 4 (. i-e-- <br />[A-tilling Party [eFacility 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 <br />2-e)y) 6 / 2--- <br />Phone <br />5 5 <br />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 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 />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, acknowlpAth_at all site and/or <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or4yelisriVrtigintified <br />, lifT <br />this application and that the work to be performed will be done in accordance with all SAN JOgrelZflet adinance <br />laws. Y 414 ' , 0 A. DATE: <br />project <br />on this <br />Codes, <br />authorize the <br />HEALTH <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 />Ej,, <br />, <br />/f? Q LEN C AttAffiti e CAllil, 014-m, <br />' rr Q • r DE-p N7-qt kis7-,,,,,, <br />at the above site addreW,t4reby <br />JOAQUIN COUNTY ENVIRONMENTAL <br />Accepted By AINf-CA <br />Assigned To kot c/o Ho <br />1 ir <br />Linked FA ID \ 00)..2.1!) 0 <br />Date Slu 9.....r.„) <br />y <br />PE 1( )03 Fe$ 9):06) Recq7 01,0(9 1 <br />0 Cash 0 Check # R Confirmation # <br />,-. --- 14.,b-4- lat--- <br />Payment <br />Received By <br />Rev 07/10/2024