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❑ New Facllily Existing facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> facility Name "" -" - -- <br /> Site Address (} — _ .. State ZIP <br /> a- arC KO/�( -- Cite <br /> APNSupervisor District <br /> Type of Service ❑Application for ❑Consultation Change of Owner ❑Repairs nr Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number - <br /> pumper truck IN <br /> toper <br /> Contact Types p Billing Party ❑Facilit Owner <br /> required Y ❑Facility Conta 0 Proprrly Burt er �Contractor ❑Architect <br /> ❑Billing Pariy ❑ Facility Owner Tacility Contact JITFFoperty Owner ❑Contractor ❑Arehrtect <br /> First Name Last name contractor, indicate type and license number <br /> A4 -4- <br /> Address City State ZIP <br /> u Tl v, C A <br /> Phone hone Email <br /> g 019&9 <br /> ❑Billing Party ❑Facility Owner 0 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 /> i <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contracor - �`,-,.,❑Architect <br /> .. <br /> First Name Last name if contractor,in rC gpr4hc se number <br /> A <br /> Address City Stap ZIP <br /> Phone Phone Email I+U f/rTp+I+// <br /> %Cl . I <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator orauthorized agent of same,acknowledge l�l and/or project <br /> specific ENVIRONMENTAL.HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or mybusiness as identified on this <br /> form. <br /> I also certify that I have prepared this apptic�gn and tqq t the work to be performed will be done in accordance with all SAN JOAQUiN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws/ l __- ---, _ <br /> APPLICANT'S SIGNATURE: PATE: <br /> �f <br /> 'WROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT 1-y-t-+ci <br /> --4e - <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 anyand all results,geotechnical data and/or environmental/site assessment Information to the SAN 4OAQUiN 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 /> ---•. — - -- Linked FA ID <br /> Accepted By <br /> * Vidal Pedraza Assigned To Kadeanne Linhares <br /> — —_— Record IN <br /> Date PE 1602 Fee 479 /um 'D <br /> Rev 06/12/2024 <br />