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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name (� r P ' _ n„ <br /> Site Address \� ZIP <br /> E M' X 54— City IC. State lot— c r o <br /> APN Supervisor District <br /> Type of Service ❑ Application for Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> required <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name - ` Last name 4,r r C_ If contractor, indicate type and license number <br /> Address Cit State ZIP <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 /> El Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Archi ect <br /> First Name Last name If contractor, indicate type and li @r}u <br /> F <br /> Address City State ZIP �/r fl, y <br /> Phone Phone Email �/``II Q <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site an <br /> specific ENVIRONMENTAL HEALTH EPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified onthis T <br /> form. I <br /> I also certify that I have prepa ed thi lication and that t e performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards, STATE and FEDER <br /> APPLICANT'S SIGNATURE: DATE: < < - <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ 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 HEALTH <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 /> S 6Os.�nck S . FA0QT3-4 53 <br /> ;ate, 20 - PEM R 2 Fee 00 Record NumbS (Z2,Se(TG_T 4q <br /> iq ' Is7q 2J Payment <br /> ❑ Cash El Check# Confirmation # `t Received By <br /> Rev 07/10/2024 <br />