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S' <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />State <br />Supervisor District <br />^Change of Owner□ Consultation □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />^Billing Party ^Facility Owner QQacility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />Phone Email <br />'^4 Facility Owner□ Billing Party □ Property Owner □ Contractor □ Architect <br />Nami If contractor, indicate type and license number <br />Phone Phone <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER <br />Title <br />in 2 .&<z> <br />□ Check U□ Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />□ Application for <br />Operating Permit <br />□ New Facility Existing Facility <br />State <br />Type of Service <br />Requested <br />Comments <br />First Name <br />44t>lhiv Cir <br />Phone <br />PROPERTY / BUSINESS OWNER <br />Loco Pobc <br />LU- Lodi ^1 <br />APN <br />PE <br />State <br />ski/eirferprlrscs llcg^rki f L <br />^Facility Contact <br />Accepted By <br />Jgy V <br />Date .5\22>\2S <br />Last oarpe 4'3 <br />cMi <br />Last name <br />Linked FA ID <br />Record Number <br />Confirmation It <br />Assigned To <br />_Francis co k- <br />Fee <br />FjlstNamex *Stgph^ni-e <br />Hallow Gr <br />iFskv'eiokirprise’S / I > oono <br /> <br />If contractor, indicate type and I <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site ana7m4j^y^^' <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 JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. ’ O ^2 <br />APPLICANT'S SIGNATURE: DATE: O ' C? <br />Payment , i fTJ~^ <br />Received BytU-^