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• <br /> New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />.Facility Name <br />ttea.Y4 1-1 MX _ ce,!e•,, <br />Site Address <br />n-Ln3 Obc/utin k)..e <br />City i . <br />( Ottk/V\-(1)CN <br />Stater ZIP <br />9 5 33 0 <br />APN 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 El Other <br />Comments <br />t•-)e,-) C-F-0 c1cAss Vt <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 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />cif Billing Party ,Facility Owner j8:1 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last namtrx .., If contractor, indicate type and license number <br />ri Lr9-3 No-ALY, fi,02_ <br />ity <br />V-01) <br />State n <br />L:IC,1/4 <br />ZIP <br />7c 330 <br />phone Phone Phone Email <br />Rtzoori -,9-? ,voc.), Coln.) TlociOnl' I <br />\-- <br />? \ -Q-Cr2SZ <br />--\--c) <br />4-"- ( 1 r'\ + <br /> <br />X <br />\ k) <br />-Q._ fv-c,,,\\ c)-(- o---- ----- <br />_ <br /> <br />\ CA 9-c( cz <br />Li Contractor Li Architect <br />If contractor, indicate type and license number <br />State ZIP <br />El Contractor <br />PA • t*. <br />PO chitect <br />--7-NC\C"(\_\S <br />(r_ <br />If contractcREGE .. it ense number <br />State S&0 3 2024 <br />SMEt4vj°tARQouNimEt4 eNgruAtirf <br />K EALl ti DEPTMENT <br />t <br />le <br />of same, acknowledge <br />billed to me <br />with II SAN <br />1 31 <br />that all site and/or project <br />or my business as identified on this <br />JOAQUIN COUNTY Ordinance Codes, <br />2_ 1 <br />I also certify that I have prepared <br />Standards, STATE and FEDERA <br />APPLICANT'S SIGNATURE: <br />El 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 />this application and • that the work to be performed will be done in accordance <br />DATE: <br />- <br />OWNER D 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 13 Lt <br />at the above site address, h iiriA„- tlie <br />JOAQUIN COUNTY ENVIROWENTAL H Amp <br />`*/) <br />2 4 <br />Accepted By <br />vtaci P. <br />Assigned To <br />..:ctc.A ec,1/4-)ne., i- . <br />Linked FA ID Sky JoAQ,. <br />oivii? umico ilp:Atni on/A4 ...N thy ry <br />Date i <br />OCI 10512024 <br />PE , toce Fe <br />e $1 86.e.0 ..---- 4 t K.0 • <br />Record Number pep rAt <br />Ap2_44=9q8 Ai,74,,,A,. ,., <br />CI Cash 0 Check # 74firmation # LiK7 6 /f° 2 ( <br />Payment <br />Received Byi <br /> <br />-- <br />Fr2L-t oolg-2 Rev 07/10/2024