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T 11 New Facility GY Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name i <br /> �' k- 3-�r� ' �r✓.rm L�1� c� <br /> Site Address Cit State ZIP <br /> APN Supervisor District <br /> Type of Service W. pplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License PI to Number VIN <br /> pumper truck <br /> Contact Types 61,41ing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ZR7ontractor ❑Architect <br /> required <br /> illing Party ❑Facility Owner ❑Facility Contact ❑Property Owner gKontractor ❑Architect <br /> -T <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> hone Phone Email <br /> ❑Billing Party &LAcility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect I <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> r 2-1 cA c,+e` Ivv 9"k Cr 9s-2-15 <br /> P one Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> __ I <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> I j <br /> Phone Phone Email <br /> --I <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 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 /> APPLICANTS SIGNATURE: DATE: I Z -30 Z j <br /> ❑PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT _InAA-- 'kT✓ -- <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 HLALI II <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. 1 <br /> Accepted By Assigned To Linked FA 10 <br /> Date PE Fee Record Number <br /> Payment <br /> ❑Cash ❑Check# ❑Confirmation# I Received By <br /> i <br /> Rev 07/10/2024 <br />