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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br /> Change of Owner Repairs or Remodel Consultation Other <br />VIN <br /> Contractor Billing Party Facility Owner Facility Contact Property Owner Architect <br /> Property Owner Contractor Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license number <br />Email <br /> Facility Contact Property Owner Contractor Architect Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />Address State ZIPCity <br />EmailPhonePhone <br /> Property Owner Billing Party Facility Owner Facility Contact <br />numberFirst Name Last name <br />DECAddressCityState <br />Phone Phone Email <br />DATE: <br /> PROPERTY / BUSINESS OWNER OPERATOR/MANAGER . OTHER AUTHORIZED AGENT <br />Title <br />Linked FA IDAc<■d By <br />PE <br /> Check#Confirmation # <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 />DEPARTMENTas 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 />Payment <br />Received By <br />IjcatJoj^and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />/?. - IQ-ZS <br />Last name <br />^77 <br />Phdne z <br />Type of Service <br />Requested <br />Comments <br />ApplicationForm <br />5 S/d-l- ‘0/1 / <br />I S I I 311^ <br />License Plate Number <br />2- <br />First Name 1 <br />me ■ . Phone <br /> Billing Party <br />Facility Name <br />p;?:-' I <br />C.he^e <br />APN Supervisor District <br />□ Contractor PAYMENT <br />If contractor, <br />SAN JOAQUIN COUNTY <br />ENVIRONS ENTAL <br />__ _ _ FTH DEPARTMENT a <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 identified on this <br />form. <br />I also certify that I have prepared this. <br />Standards, STATE and FEDERAL’Iaw^ <br />APPLICANT'S SIGNATtfRE: <br />HI <br /> Cash <br />ZIP <br />State6^ <br />Z4 <br />Assigned To <br />1