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11 New Facility 0 Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Form <br /> Facility Name Application <br /> Site dr ------- State Z1 <br /> 2yl'�o f , 3 '��-ec ........... <br /> APN Supervisor District <br /> oall ^ <br /> 71.9 <br /> Type of Service 0 Application for El Consultation D Change of Owner 0 Repairs or Remodel 91 Other <br /> Requested Operating Permit <br /> Comments SSWO <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact <br /> n'; Types D Silting Party D Facility Owner ❑Facility Contact D Property Owner C7 Cantractor ❑Architect <br /> requi <br /> Billing Party 101 Facility Owner 11 Facility Contact Iroperty Owner 0 Contractor 0 Architect <br /> �r�p e_� <br /> First-Name <br /> Last if contractor,indicate type and license Zrnb�, <br /> ems. <br /> Address city State <br /> 9 6:5-Ll zlp.. 5 3& <br /> Phone Phone it <br /> fv1 <br /> 0 Billing Party 0 Facility Owner 0 Facility Contact Property Owner D Contractor 0 Architect <br /> First Name pp Last nam@ if contractor,indicate type and license number <br /> Address ZI <br /> _clty.. isdi e q-N st',_tL)� <br /> Phone Phone T <br /> 0 Billing Party 0 Facility Owner 0 Facility Contact D Property Owner 0 Contractor Architect <br /> First Name Last name if contractor,indicate type and IiISUse number <br /> Address city State ZIP —AZ/ i <br /> Phone Phone Email 20�6 <br /> AN <br /> V41p,-01V, <br /> BILLING ACKNOWLEDGEMENT:1,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all siizlp'r'oject <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,44ification and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Code,,-,, <br /> Standards,STATE and FEDERAL laws <br /> APPLICANT'S SIGNATURE: DATE: <br /> 0 PROPERTY/BUSINESS OWNER 11 OPERATOR/MAdAGER 0 OTHER AUTHORIZED AGENT <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 environmental/site assessment information to the SAN JOAQUIN COLIN I Y ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepted By ACA4-) t Assigned 401_1_� Linked FA ID <br /> Date Fee 2,77 PE 7,toi­0 1?,— RecordNurnb r <br /> 11 Cash D Check# Confirmation k 'V Payment <br /> ILL Receivedd By By <br /> RevOY/10/2024 'P <br />