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❑ New facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name 1 I p <br /> Site Address City State ZIP <br /> lalL S - S'kece- (\ArJ eST6 CA S351 <br /> APN Supervisor District <br /> Type of Service ❑Application for r-onsultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Numb ViN ' 1 <br /> pumper truck /I 3 �/1J'r �/ Q t�T � 1 I )� A <br /> Contact Types ❑Billing Party ❑Facility Owner El Facility Contact 0 Property ner Q Contractor ❑Architect <br /> required <br /> filling Party VI Fadlity Owner acility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name �'l Last na e t If contractor,indicate type and license number <br /> Address ^` vJ f3� 1 �I F' �Ci� �IN State C ZIP <br /> Phone (/! Phone I" Email <br /> C.P. tVf <br /> l� <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 <br /> 1JArM"-r <br /> First Name Last name If contractor,in c lumber <br /> Address City State ift P 01(, <br /> Phone Phone Email MAUC ENvrR� IN COUNTY <br /> MENTAL <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 ap Ilcatio n that th work to be performed will be done In accordance with all AN JOA UIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIG NATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑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,geotechnicai data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <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 r Linked FA ID <br /> /.�Cd <br /> JJ C4,0 + rr <br /> Date PE Fee Record Number <br /> c��lz2lz ���3it-iz PP24W'-+4 <br /> Payment <br /> ❑Cash ❑Check# ❑Confirmatlon# <br /> Received By <br /> Rev 07/10/2024 <br />