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s <br /> New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address ZIPCityState <br />EmailPhonePhone <br /> Architect Facility Owner Facility Contact Property Owner Contractor Billing Party <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPCityStateAddress <br />Phone EmailPhone <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER <br />Title <br />Assigned To <br />Fee <br />E Confirmation # <br />Rev 07/10/2024 <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />City <br />2** ' <br />License Plate Number <br />Type of Service <br />Requested <br />Comments <br />TIN <br />‘y Yd <br />Ivor's- §8" <br />Supervisor District <br />C Kcx'a <br />If mobile food truck or <br />pumper truck <br />ZIP <br />/Ki Billing Party <br />State <br />___ <br />2123^3? 2-S <br />City . <br />Accepted By^j) <br />____C sc <br />PEl.Hx <br /> Check tt <br />Last name . <br />ytr^tror <br />Date , / <br />O-l l/zS <br /> Cash <br />First Name <br />Address My gy <br />Phone Phone Email . . <br />^7o0l7/Z ^/7 p- <br />ZIP <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 cyjjnance Codes, <br />X Standards, STATE and FEDERAL law*. I . ty ? 7 C' <br />/ V APPLICANT'S SIGNATURE: DATE: ' J <br /> PROPERTY/BUSINESS OWNER OPERATOR / MANAGER OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required J 202$ I <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site add^^j^hv authorize tW <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br />DEPARTMENT as soon as it is available and at the same time it Is provided to me or my representative.77y <br />State <br />- dT/T-