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❑ New Facility Existing Facility <br /> (needs SRt#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address j,#„ �rL Cit v`' 6� State „ ZIP A � ` <br /> APN Supervisor District l� t//�iIILIF- (�% M <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner )F et�airs 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 Rl Billing Party ❑ Facility Owner ® Facility Contact ❑ Property Owner ® Contractor ® Requestor <br /> required <br /> -masifilling Party ❑ Facility Owner cility Contact F <br /> Property Owner ntractor ❑ Architect <br /> First Name / Last name If contracior, Indicate type and license number <br /> Address �6{, 40' Wgv-L/_ OvSe vt/ Cit�av✓ G State ,r ZIP�m <br /> P one p f- Phone ''1 Email L <br /> 3�& ( 7CeS•Cw-t. <br /> ❑ Billing Party acility Owner Apcility Contact ❑ Property Owner ❑ Contractor ❑Architect <br /> First Name4 , n ` Last name If contractor, indicate type and license number <br /> Address '�10 n �y rb-4� Cit ^/' State 4 ZIP_ n� <br /> �J (.Iv h C'dJ vv <br /> Phone Phone Email C <br /> U6 '32q- 00 <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑Property Owner ❑Contractor r ' ct <br /> First Name Last name If contractor, indicate type I r <br /> Address City State ZI Ir' <br /> SqH ?2 <br /> Phone Phone Email <br /> yE4 ti!iR Q /,y c <br /> BILLING ACKNOWLEDGEMENT:I, the undersigned property or business owner, operator or authorized agent of same,acknowledge tha or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as i �on this <br /> form. <br /> 1 also certify that I have prepared this application and that rk to be performed will be done in accordance with all SA JOAQUIN COUNTY Ordinance Codes, <br /> Standards, STATE and FEDERAL law �j <br /> APPLICANT'S SIGNATURE: DATE: <br /> ElPROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 1ER <br /> L AUTHORIZED AGENT ��B/ ��`"Rt na <br /> Title / <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Fe Se%I ZG.S <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 BtL ` Assigned Tq � l� Linke 1 :7-# <br /> JCS!—�'n1 / Z / <br /> Date/a �� PE � ) �� Fee n Rec/ord�luR a 5 m 15 m <br /> ❑Cash ❑Check# Confirmation# 7g�t 0 I '}� Payment <br /> Received By <br /> Rev 07/10/2024 2 of 6 <br />