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EMAI L.ED ❑ New Facility ❑ Existing Facility <br /> "San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address i State ZIP <br /> IV az k Ir�l �- ►� e vt G 3 <br /> APN Supervfsgr 'strict <br /> t_lf * <br /> Type of Service ❑Appli tion for ❑Consultation ❑Change of Owner ❑Repairs or Remodel Other <br /> Requested Operating Permit 'n / �j� <br /> Comments (Z�V��i� r l� SQ11 5�� Y1�+ 0Qd1A1 `' ram <br /> 1\ IN f� <br /> rp'fu <br /> mobile food truck or License Plate Number VIN <br /> mper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party 4 acility Owner ❑Facility Contact 9 Property Owner ❑Contractor 7iArchitect <br /> First Nam*C4 V1ne, Last name —2J If contractor,indicate type and license number <br /> ��JJ _ <br /> Address T Q Fax I Cam'. Cit / State <br /> a � yLn �36 <br /> Phone Phone Email <br /> O 11 LC) <br /> ❑Billing Party ❑Facility Owner EL �'t <br /> ity Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name me If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑ tt ct <br /> First Name Last name If contractor,indicate type AQN-ftsi AN 4� <br /> Address City State <br /> Phone Phone Email <br /> c <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that a '* or pitiect <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as id �on this <br /> form. <br /> I also certify that I have prepared this gpplic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL lav�. —7/-Z�/1,k, <br /> APPL�CANT'SSIGNATURE: _ DATE: <br /> tw<PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑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,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 /> Accepted By Assigned To Linked FA ID <br /> /,tii J� iGjLt q�o�-ems <br /> Date PE Fee Record Nu er <br /> 071 o -�.�014100 <br /> ❑Cash ❑Check# `IA Confirmation it '//��(� 'IJ Il Payment <br /> N v V Received By <br /> Rev 07/10/2024 D��itiG 5"✓""9��r � '����"r� <br />