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❑ New Facility ©Y Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address City State ZIP <br /> S+0 ('11 9152ts <br /> APN Supervisor District <br /> Type of Service pplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments f,,y1 1 1 <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types OWilling Party ❑Facility Owner ❑Facility Contact ❑Property Owner Contractor ❑Architect <br /> required <br /> 13 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Fiir;t Name Last name If contractor,indicate type and license number <br /> 11 r-C I fm ��b� c v�`c LacF 1(. (j,0UZrs )vc) <br /> Address City State ZIP <br /> `' H -e�� Iu l- is �Gtilr n� s f� �3 v� <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner Wacility Contact 7perty Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> cl 21G—rrf. 1� <br /> Address CityC_ / State ZIP <br /> l 1`1c L(�S i v S J�. I n��s C <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑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 /> BILLING ACKNOWLEDGEMENT:1,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 that the work 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: t�L- r S 1 t + t� DATE: <br /> ❑PROPERTY/BUSINESS OWNER IYOPERATOR/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 HEALI H <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 Record Number <br /> Payment <br /> ❑Cash ❑Check# ❑Confirmation# Received By <br /> 1 <br /> Rev 07/10/2024 <br />