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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name Jene Wah, Inc <br />Site Address City State ZIP5638 N Pershing Ave Stockton CA <br />Supervisor District <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br />E Billing Party Facility Owner :acility Contact Property Owner Contractor ® Engineer <br />tSniilling Party Facility Owner Property Owner Contractor Architect <br />First Name Last name If contractor, indicate type and license number <br />Address State ZIP 7^2-7 <br /> Billing Party Property Owner Contractor Engineer <br />If contractor, indicate type and license number <br />State ZIP <br />CA 95816 <br />Phone <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br /> PROPERTY / BUSINESS OWNER <br />Assigned To <br /> Confirmation # &G cDC\ 3> Check # <br />Rev 07/10/2024 <br />Contact Types <br />required <br />Last name <br />Vu <br />Email <br />hvu@vsacdesign.com <br />City <br />Sacramento <br />Date <br /> Cash <br />Accepted By c <br />(X) Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <br />Cc^yy\ <br />'^Facility Contact <br />Type of Service <br />Requested <br />Comments <br />First Name <br />Huan <br />Address <br />PO Box 163686 <br />Phone <br />926 752 2022 <br />Record Number <br />Payment <br />Received By <br />APN <br />10815012 <br />S £ Clvtfdy 7T____ <br />Email <br /> Facility Contact <br />Fee. <br /> Facility Owner <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN Ji <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ' ^^^BATE: < <br /> OPERATOR/MANAGER ( <br />. - - .. _. SAN JOAQUIN COUNTY Ordin <br />-------- <br />AZfeTHER AUTHORIZED AGENT , <br />Tit'e <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required C^^7/> <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEfttW/Ty^" <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. * <br />A <br />i VvA. ______ <br />PE <br />I f