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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name , <br /> Site Address City State_ ZIP <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 /> H mobile food truck or License Plate Number VIN <br /> pamper truck 5 ' ?) 3pp <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> IIA�Iling Party FaclJity Owner ❑Facility Contact ❑Property Owner ❑Contractor L7 Architect <br /> First Nam Last name If contractor,indicate type and license number <br /> Address r,� City Stat Z Zf <br /> V <br /> Pho Pho a Email <br /> 7 ] I DllrbCC'► TD. Vin} C�tc t Q.At'0 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license r�mber <br /> Address City State ZIP 024 <br /> SAN 10AQUf <br /> iv <br /> Phone Phone Email H�4L7N t7 pARr AL N <br /> ANT <br /> ❑Billing Party ❑Facility Owner ❑Fatuity 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 /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of some,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 aiso certify that I have prepared this applic tion an tha he work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL I s. _ <br /> APPLICANT'S SIGNATURE- c_ DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTH ER AUTH ORIZE D AGENT <br /> Title <br /> if APPLICANT is not the BILLING PARTY,proof of authorization to sign Is required <br /> AUTHORI7.ATION 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 B I111 Assigned To Li ed FA ID_ J <br /> liq <br /> Date le Isy PE I r'Jl/„o 3 Fee 1�� Re •I 5 b <br /> ❑Cash ❑Check a C (97� <br /> onfirmation Payment <br /> q 13nReceived By <br /> Rev 07/10/2024 <br /> �� + <br />