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San Joaquin County Environmental Health Department <br />Srte Addons <br />APN <br />J&change of Owner Consultation Repairs or Remodel Other <br />License Plate Number V1N <br /> Contractor Faafoty Owner Architect Property OwnerBilling Party Facility Contact <br /> Architect Contractor Facility OwnerParty Facility Contact Property Owner <br />If contractor, indicate type and license number <br />Ziddress <br />■ CO <br /> Architect Contractor Facility Owner Facility Contact Property Owner EiBsng Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />Oty State ZIPAddress <br />EmadPhonePhone <br /> Property Owner Contractor Facility Contact Facility Owner Bilfing Party <br />Last nameFirst Name <br />City StateAddress <br />EmailPhonePhone <br />will be <br />DATE: <br /> OPERATOR / PROPERTY / BUSINESS OWNER <br />Assigned ToAccepted By <br />PE \jzo7- <br />Type of Service <br />Requested <br />Comments <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 enworunental/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 /> Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all <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 'HT <br />form. \ <br />1 also certify that I have prepared application and that the work t^be <br />Standards. STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />last nape f) <br />(ucw&xv <br />f <br />First Name i I <br />^l^qcei <br />Email <br />or coovA \n <br />Phone Phone <br />Slate <br /> Architect <br />___BUgitaur <br />If contractor, indicate type and icentammiSef J / <br />..-lULng.^ <br />Linked FA ID <br />____r/Q f? o n / 0 ? <br />Record Number _ I . _ J <br />S^'2t=>0\XVg.\ <br />C) o <br />\ ) \CXC5Cn\Ottf <br />in accordance with an SAN JOAQUIN COUNTY Ordinance Codes, <br />py/o vpoq- <br />OTHER AUTHORIZED AGENT Q/Q <br />Application Form <br />\\Q>0 kY Urfixx <br />Supervisor District