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San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address State <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Property Owner Billing Party Facility Owner Facility Contact Contractor Architect <br />(Z0Billing Party ^ZTFacility Owner Property Owner Contractor Architect^Jatility Contact <br />If contractor, indicate type and license number <br />State <br /> Contractor Architect Property Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />City State ZIPAddress <br />EmailPhonePhone <br /> Property Owner Contractor Facility Contact Facility Owner Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT <br />Linked FA IDAccepted By <br /> Check tt <br />Rev 07/10/2024 <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 />CT <br />__________ <br /> Confirmation tt <br />Type of Service <br />Requested <br />Comments <br /> Application for <br />Operating Permit <br />(Av <br />lf mobile food truck or <br />pumper truck <br />CiW^ <br />Supervisor District ' <br />LasLname \ , <br />citv_ > C i <br /> Facility Contact <br />First Name [ <br />i To <br /> Facility Owner <br />^fc3Sh J 7^3 <br /> New Facility Existing Facility <br />Z9 (J 2^2.3 7 <br />.Re"rdN^ 9 501 38^ <br />Payment fi~f> ~ ' <br />Received (/ <br />If contractor, indicate type antjlfefejj^irrT* 1 <br />[^'^025 <br />____________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on thi/*' <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. 4- I I <br />APPLICANT'S SIGNATURE?? ________________________________ DATE: ----------Q/ \ I---------------------------- <br /> PROPERTY/BUSINESS OWNER OPERATOR / MANAGER OTHER AUTHORIZED AGENT <br />Title