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z, ❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> �a AVL p LA-Q»'1 Lt— <br /> Site Address City State ZIP <br /> CA <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types illing Party ORfacility Owner acility Contact Property Owner FrContractor ❑Architect <br /> required <br /> ❑Billing Party EirFacility Owner ❑Facility Contact Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> F'ov_wP,o-D LA-r-3 Dr-Ii-L _ <br /> Address <br /> �q qq s. q')SI-z Q City D. vl-�AN State ZIP T E CA C� 61 S 33 4 <br /> Phone_` one Email <br /> illing Party ❑Facility Owner XFacility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> 0S�JAI, a Cs7Q,pE'eo _ <br /> Address City State ZIP <br /> 11 �. A u ST I P F--Q M A-►,'CE C.4 CA <br /> Phone Phone Email <br /> Cro � S(ob 2Z fLE2v G�$ . C o ✓� <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> ck,A f2 k <br /> Address City State ZIP <br /> 107 0 LAJlr\ (Lo c� �• S�TTf t /��*o Colz A C-A <br /> Phone II__ Phone Email` 1- <br /> q 1 p— 2/ Y41 Cc ,gT�1�Y 1 ti (Dk%( �Q.� D <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 rk to be performed will be done in accordance with II S N JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL I I Z 7 <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑64RATOR/MANAGER ❑OTHER AUTHORIZED AGENT RECEIVED <br /> FINED <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 ENVj4 VI0J1IAL[tt H <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. 11 <br /> Accepted By Assigned To Linked FA ID ` UN <br /> UMFN£V <br /> HEALTH TAL <br /> Date PE Fee Record Number T <br /> 1 5 a <br /> ❑Cash heck# !-o loci 5-sl ❑Confirmation# Payment <br /> Received By <br /> Rev 07/10/2024 A ,; C.1` C O � <br />