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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> & oL-D STAR Gt-c <br /> Site Address City State ZIP <br /> 4 v3 n/. 7—ue R . s o C -7saz <br /> APN / Supervisor District <br /> J2 — 4 <br /> Type of Service ❑Application for VConsultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> S541- 4AID OWTS R9VIC441 <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party Facility Owner ❑Facility Contact Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> O96A Al <br /> Address City State ZIP <br /> 00 R VEJZ[,A J tv 4A 51016- <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Contractor ❑Architect <br /> First Name Last name If contractor,indicat type and license number <br /> 5 <br /> Address Cit State ZIP <br /> P. D. 0 37 L S f <br /> Phone Phone Email <br /> ao - 2• <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> PA <br /> First Name Last name If contra cto Mica eAnse number <br /> CEll j=n <br /> Address City State ZIP <br /> Phone Phone Email <br /> SAN JO <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same Y I t Iu and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed tot 1 S9l ified on this <br /> form. <br /> I also certify that I have prepared this a&atind that t w r to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /+� <br /> ❑PROPERTY/BUSINESS OWNER El OPERA OR/MANAGER OTHER AUTHORIZED AGENT ( I/Jli /yGJ1A1,0EP— <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 /> Date PE Fee gg�qqd N behh <br /> -z(v Z(aZ �l [ .'Wa 01V In V ? <br /> Payment j <br /> ❑Cash Check# ❑Confirmation# Received <br /> Rev 07/10/2024 ct <br />