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E^Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Property OwnerBilling Party ^Facility Contact Contractor Architect <br />If contractor, indicate type and license number <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />City State ZIPAddress <br />Phone EmailPhone <br /> Property Owner Contractor Architect Facility Contact Billing Party Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPCityAddress <br />EmailPhonePhone <br />DATE:1 /9fi/9n9K <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER <br />Title <br />Assigned ToAccepted By Vidal Pedraza Francisco Ruiz <br />FeePEDate 1791/29/26 1602 <br />Confirmation 214759841 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />Last name <br />Wanq <br />Email <br />qiqi995225@gmail.con <br />ZIP <br />95242 <br />ZIP <br />95212 <br />City <br />Lodi <br />City <br />Stockton <br />State <br />CA <br />p4 czri cc#: <br />Rev 06/12/2024 <br />Phone <br />7073344258 <br />State <br />CA <br />[^■Facility Owner <br />Type of Service <br />Requested <br />Comments <br />First Name <br />Qi______________________ <br />Address <br />2221 Bartram Run Way_____ <br />Phone <br />Supervisor District <br />District 4______ <br /> Application for <br />Operating Permit <br />Facility Name <br />________Masayama <br />Site Address <br />235 Lakewood Mall <br />APN <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 JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. nATF. PAYMENTAPPLICANT’S SIGNATURE: Qi Wann_________________________________________ DATE: 1790/9090______________________ iWi 1 <br />RECEIVED^^ROPERTY / BUSINESS OWNER <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required JAN 2 9 20K <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 ENVIRONj^^CO JNTY <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Record Number <br />5Ra(p0 f