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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> S ro A,+A-- — CityState ZIP <br /> St _ Sitic�ni7 , , , ! "1 r �w4. <br /> J- <br /> APN Supervisor District <br /> Type of Service L- plication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or Li ense Plate Number VIN _ <br /> pumpertruck a ( j— <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party 0racility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last na a If contractor,indicate type and license number <br /> ft-�e-ti�Y <br /> Address <br /> City State ZIP <br /> P/hone Phone Email <br /> Lt0'J - -L i 1� <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 /> ❑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 /> 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDER I S. 1 _ <br /> APPLICANT'S SIGNATURE: !— �\ �)� '�—"1 � DATE: ( � 1 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title FcFiF <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,here! t�°r ze the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIR(;r *NTA H A)H <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 /> 3e� C. CWN � — �"2-13 'ti <br /> Date PE Fe Record Number <br /> i(CU'3i �.wccc�- s¢�-iCA3 <br /> ❑Cash ❑Check# PJ Confirmation# Iq �{ n/ I J�� Payment <br /> 1 1 v v�Ui l v Received By <br /> Rev 07/10/2024 <br />