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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form VP,2tI3)2i2 <br /> Facility Name , <br /> t94 ( e <br /> Site Address City State ZIP <br /> A'P N Supervisor District <br /> Type of Service )(Application for ❑Consultation ❑Change of Owner ❑Repairs 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 ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> §�Billing Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Fi Name Last me If contractor,indicate type and license number <br /> Address /L , o / City f State 21P <br /> yr I!\r a <br /> hone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 0 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 ❑ t <br /> Archi <br /> PAY , <br /> First Name Last name If contractor,indicate type and lic a tr1"e <br /> 1p,� <br /> Address City State ZIP Ji 18 <br /> YY2._, <br /> Phone Phone Email SM JOAQUIly COU Ty <br /> ENV1RONM <br /> "GwMLIt1L)EPARTMET <br /> BILLING ACKNOWLEDGEMENT:f,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 aDd that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. ' J <br /> APPLICANT'S SIGNATURE: DATE: K � [ <br /> ❑PROPERTY/BUSINESS OWNER II OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <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 /> Accepted By Assigned To Linked FA ID <br /> �J%dc'! ClCA A61(, IVY <br /> Date PE Fee Record Number <br />