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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Contractor Architect Billing Party Facility Owner Facility Contact Property Owner <br />Last nameFirst Name If contractor, indicate type and license number <br />Address State <br /> Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br /> Billing Party Facility Owner Contractor Facility Contact Property Owner Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />PhonePhone Email <br />nd tl ;he wj <br />DATE: <br /> PROPERTY / BUSINESS OWNER OTHER AUTHORIZED AGENT OPERATOR/MANAGER <br />Title <br />f ' <br /> Confirmation It Check W <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <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 apph^atL <br />Standards, STATE and FEDERAL laws. /^T^ ? <br />APPLICANT'S SIGNATURE^ <br />Type of Service <br />Requested <br />Comments <br /> Facility Contact <br />Linked PAID <br />Record Number <br />SP.-z.l5Q)tq>3ei <br />Payment <br />Received By <br />Application Form <br />m/fa CL./ FrF/i /I <br />Supervisor District <br />ZIP 9 <br />City i/r <br />Date <br />a^5h^( '//S' <br />Accepted By nV'dcJL P <br />PE <br />ZIP <br />Assigned To <br />Fee iws. <br />Fe performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required -■ ft <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addressj ^thorize^McJJ" | <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIf^^kp^/?HA'4t^k <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.'Af <br />State c <br />11 //icktri/ <br />W? ^ort/ v/y <br /> Billing Party Facility Owner