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New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />CitySite Address <br />APN <br /> Change of Owner Repairs or Remodel Other Consultation <br />License Plate Number VIN <br /> Contractor Facility Owner Facility Contact Property Owner Architect Billing Party <br />JJ^Billing Party Property Owner Contractor Architect Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />Address State ZIP ^26^ <br /> Property Owner Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />DATE: <br />J^PROPERTY / BUSINESS OWNER 01 OTHER AUTHORIZED AGENT JOR/MANAGER <br />Title <br />Assigned To <br />FeeI <br /> Cash Check #Confirmation « <br />Rev 07/10/2024 <br />Payment <br />Received By <br />Contact Types <br />required <br />Type of Service <br />Requested <br />Comments <br />-IWpoyif <br />Phone <br />^1^9; <br />Application Form <br />N- <br />Supervisor District <br />CT <br />Date <br />'^Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <br />Existing Facility <br />Phone Email <br />(? yahoo <br /> Contractor <br />State . <br />Ci] <br />_______ <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 iden>jfied on this <br />form. <br />I also certify that I have prepared this application and thaj-tte work to "Be perfornled will be done in accordance with all SAN JOAQUIN COUNTY'^t^tadOQe'Codes, <br />Standards, STATE and FEDERAL laws. / jL ja —i -n q <br />APPLICANT’S SIGNATURE: ( T A DATE: II}' I ’ L? <br />'> . <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, n&r'4b.y^LiljHoH/e‘ifhe ' <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL H^AL?F>4S’A/>• <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Accepted By <br />_______CA1* < S C <2 <br />PE