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□ New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address <br />APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />^(facility Owner□ Billing Party □ FacilityContact □ Property Owner □ Contractor □ Architect <br />□ FacilityOwner□ Billing Party □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />State Q'A <br />□ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPAddressCityState <br />EmailPhonePhone <br />□ Contractor□ Property Owner□ Billing Party □ Facility Owner □ Facility Contact <br />Last nameFirst Name <br />City StateAddress <br />Phone EmailPhone <br />DATE: <br />^PROPER! Y / BUSINESS OWNER □ OPERATOR / MANAGER <br />Title <br />Assigned ToAccepted By Lydia BakerVidal Pedraza <br />FeePEDate5/14/26 1602 179 <br />Rev 06/12/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative._______________________________ ___________ <br />Phone <br />gio- 200-2-5^ <br />Type of Service <br />Requested <br />Comments <br />W^Application for <br />Operating Permit <br />___________Application Form <br />Food Group, LLC <br />Klgl yj. March (yi,_____ <br />Supervisor District <br />Record Numbl^££ip (7244-1^ <br />Existing Facility <br />with all SAN JOAQUIN COUNTY Ordinance Codes, <br />4/(1 <br />Last nam1-_top^G_ <br />Email <br />0^ igon, Mu'fAru—— <br />______tic <br />AddreW Vv/, <br />Phone <br />State <br />□ Art^jtect <br />If contractor, indicate type andlji <br />________________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site Stid/ph,pxQiejH- <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on <br />form. <br />1 also certify that i have prepared this application and that the work to be performed will be done in accordance with all SAN Ji <br />Standards, STATE and FEDERAL la.fky U /TT I V3/ <br />APPLICANT'S SIGNATURE: / I (/ \ <br />CTOTHER AUTHORIZED AGENT