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New Facility 0 Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> TLAptjEp ACADy-My WEST <br /> Site Address City State ZIP <br /> 5C YM C_ NTC? <br /> APN Supervisor District <br /> i <br /> Type of Service pplicacon for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> GH 0' 'sr-c <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ©Billing Party ❑Faculty Owner ❑Facility Contact ❑Property Owner ❑Contractor IDArchitect — — <br /> re(u4red <br /> P Billing Party I eacllity Owner 17 Facility Contact C7�A roperty Owner ❑Contractor ❑Architect <br /> First Name // Last name If contractor,indicate type and license number <br /> L 00 L- rk <br /> Address City State ZIP <br /> 4 05 VAN sr. L0IDXs, <br /> Phone Phone Email <br /> 2 1- 22 5- DWss L.ov usti•Nrr <br /> ❑Billing Party ❑Facility Owner fia Facility Contact ❑Property Owner C.1 Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> V. N T r <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor ❑ArchiteZn <br /> First Name Last name If contractor,Indicate type and licenseIV <br /> Address City State ZIPVFW <br /> Phone Phone Email0�5BILLING ACKNOWLEDGEMENT:i,the unders€gned property or business owner,operator or authorized agent of same,acknowledge that all siteVspecific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as idntified o � <br /> form. E <br /> I also certify that I have prep�san an t t work to erformed will be done in accordance with all SRN JOA4UIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDE <br /> APPLICANT'S SIGNATURE _� TE: <br /> ❑PROPERTY I BUSINESS OWNER [I OPERATOR/MANAGER WOTHER AUTHORI D AGENT g KPIA hVf M YPGf�r OF O� f��tOnS <br /> Title <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 environment/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soar as it is available and at the same time it is provided to me or my representative. <br /> Accepted By Vidal Pedraza Assigned To Francisco Ruiz Linked FA ID <br /> Date 8/6/2025 PE 1602 Fee 179 Record Number <br /> O Cash ❑Check tr Confirmation k 206601869 Payment i <br /> Received By <br /> Rey 07/10/2az4 A P a 5 0 g-5 -7 ep <br />